| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1354 |
|
3,280 |
605 |
$135K |
| D1120 |
Prophylaxis - child |
1,993 |
1,993 |
$81K |
| D0120 |
Periodic oral evaluation - established patient |
2,193 |
2,193 |
$60K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
511 |
250 |
$39K |
| D7140 |
Extraction, erupted tooth or exposed root |
549 |
320 |
$31K |
| D1206 |
Topical application of fluoride varnish |
927 |
920 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,797 |
1,791 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,586 |
1,586 |
$21K |
| D1110 |
Prophylaxis - adult |
358 |
358 |
$20K |
| D0272 |
Bitewings - two radiographic images |
1,150 |
1,150 |
$18K |
| D0274 |
Bitewings - four radiographic images |
541 |
541 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
606 |
603 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
50 |
36 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
115 |
115 |
$3K |
| D0240 |
|
192 |
167 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
29 |
$2K |
| D1351 |
Sealant - per tooth |
31 |
12 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
27 |
27 |
$769.50 |
| D0140 |
Limited oral evaluation - problem focused |
30 |
30 |
$399.00 |
| D1330 |
|
149 |
148 |
$0.00 |
| D1310 |
|
149 |
148 |
$0.00 |