| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
493 |
471 |
$24K |
| D1351 |
Sealant - per tooth |
437 |
87 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
264 |
214 |
$15K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
50 |
14 |
$13K |
| D0240 |
|
376 |
183 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
56 |
14 |
$9K |
| D1206 |
Topical application of fluoride varnish |
256 |
249 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
291 |
271 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
14 |
$7K |
| D0272 |
Bitewings - two radiographic images |
141 |
137 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
96 |
91 |
$4K |
| D9920 |
|
28 |
27 |
$4K |
| D0330 |
Panoramic radiographic image |
42 |
40 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
31 |
29 |
$2K |
| D1110 |
Prophylaxis - adult |
13 |
12 |
$752.13 |
| D0230 |
Intraoral - periapical each additional radiographic image |
21 |
13 |
$406.26 |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
13 |
$307.44 |
| D0602 |
|
315 |
307 |
$0.00 |
| D0603 |
|
85 |
80 |
$0.00 |