| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1354 |
|
694 |
133 |
$64K |
| D1120 |
Prophylaxis - child |
1,641 |
1,540 |
$57K |
| D1206 |
Topical application of fluoride varnish |
1,891 |
1,768 |
$40K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
177 |
100 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
684 |
642 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
993 |
925 |
$23K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
621 |
545 |
$17K |
| D1351 |
Sealant - per tooth |
626 |
101 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
131 |
67 |
$11K |
| D0272 |
Bitewings - two radiographic images |
454 |
420 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
269 |
252 |
$10K |
| D1110 |
Prophylaxis - adult |
137 |
127 |
$7K |
| D0330 |
Panoramic radiographic image |
88 |
80 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
61 |
40 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
345 |
306 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
253 |
105 |
$3K |
| D0240 |
|
121 |
71 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
89 |
63 |
$2K |
| D0274 |
Bitewings - four radiographic images |
42 |
41 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
40 |
40 |
$1K |
| D9920 |
|
15 |
13 |
$467.50 |