| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
458 |
89 |
$37K |
| D1120 |
Prophylaxis - child |
1,134 |
1,123 |
$23K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
223 |
49 |
$23K |
| D1206 |
Topical application of fluoride varnish |
923 |
919 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
444 |
443 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
442 |
440 |
$8K |
| D0272 |
Bitewings - two radiographic images |
384 |
383 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
46 |
46 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
122 |
120 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
12 |
$1K |
| D0251 |
|
48 |
48 |
$646.08 |
| D1354 |
|
33 |
12 |
$495.00 |
| D0140 |
Limited oral evaluation - problem focused |
19 |
19 |
$429.02 |
| D0240 |
|
29 |
15 |
$348.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
60 |
14 |
$275.00 |
| D0350 |
|
18 |
18 |
$221.58 |
| D0220 |
Intraoral - periapical first radiographic image |
39 |
39 |
$190.00 |
| D0250 |
|
13 |
12 |
$177.72 |
| D1310 |
|
45 |
45 |
$0.00 |
| D0603 |
|
133 |
131 |
$0.00 |
| D1330 |
|
45 |
45 |
$0.00 |