| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1354 |
|
1,755 |
501 |
$150K |
| D1120 |
Prophylaxis - child |
2,185 |
2,009 |
$64K |
| D1206 |
Topical application of fluoride varnish |
2,585 |
2,375 |
$50K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
306 |
65 |
$41K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
693 |
297 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
1,604 |
1,479 |
$33K |
| D7140 |
Extraction, erupted tooth or exposed root |
288 |
115 |
$19K |
| D0330 |
Panoramic radiographic image |
279 |
267 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
451 |
418 |
$14K |
| D0272 |
Bitewings - two radiographic images |
658 |
590 |
$14K |
| D1110 |
Prophylaxis - adult |
253 |
236 |
$11K |
| D1351 |
Sealant - per tooth |
419 |
88 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
326 |
283 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
146 |
77 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
313 |
270 |
$8K |
| D0240 |
|
378 |
247 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
82 |
81 |
$3K |
| D1355 |
|
32 |
14 |
$3K |
| D2330 |
|
23 |
12 |
$2K |
| D9920 |
|
38 |
32 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
20 |
17 |
$830.50 |
| D0220 |
Intraoral - periapical first radiographic image |
129 |
103 |
$648.94 |
| D0274 |
Bitewings - four radiographic images |
13 |
12 |
$418.54 |
| D0230 |
Intraoral - periapical each additional radiographic image |
47 |
12 |
$129.80 |
| D3120 |
|
29 |
16 |
$0.00 |