| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,176 |
460 |
$43K |
| D1120 |
Prophylaxis - child |
1,125 |
1,120 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
804 |
801 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
444 |
238 |
$21K |
| D1206 |
Topical application of fluoride varnish |
945 |
941 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
425 |
424 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
175 |
174 |
$3K |
| D0272 |
Bitewings - two radiographic images |
424 |
421 |
$3K |
| D0601 |
|
438 |
437 |
$2K |
| D0603 |
|
361 |
358 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
34 |
12 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
135 |
111 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
23 |
13 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
13 |
$490.00 |
| D0602 |
|
71 |
71 |
$410.00 |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$306.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
62 |
13 |
$42.00 |