| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,148 |
1,147 |
$56K |
| D7140 |
Extraction, erupted tooth or exposed root |
219 |
218 |
$30K |
| D1110 |
Prophylaxis - adult |
522 |
522 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
797 |
797 |
$26K |
| D1206 |
Topical application of fluoride varnish |
620 |
620 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
732 |
732 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
101 |
92 |
$11K |
| D0274 |
Bitewings - four radiographic images |
370 |
370 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
584 |
584 |
$9K |
| D0272 |
Bitewings - two radiographic images |
444 |
443 |
$9K |
| D9310 |
|
96 |
96 |
$9K |
| D0240 |
|
211 |
208 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
12 |
12 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
281 |
279 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
29 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
13 |
12 |
$2K |
| D2140 |
|
12 |
12 |
$660.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$126.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$98.00 |