| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,632 |
767 |
$66K |
| D1120 |
Prophylaxis - child |
1,850 |
1,850 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
2,705 |
2,704 |
$55K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,526 |
2,523 |
$47K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
381 |
124 |
$38K |
| D1110 |
Prophylaxis - adult |
876 |
875 |
$32K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
539 |
381 |
$29K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
644 |
636 |
$28K |
| D0272 |
Bitewings - two radiographic images |
1,550 |
1,550 |
$26K |
| D0330 |
Panoramic radiographic image |
445 |
445 |
$17K |
| D2140 |
|
352 |
274 |
$16K |
| D0274 |
Bitewings - four radiographic images |
542 |
541 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
194 |
134 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
225 |
175 |
$12K |
| D2160 |
|
162 |
123 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
103 |
70 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
600 |
599 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
246 |
246 |
$5K |
| D0240 |
|
241 |
216 |
$4K |
| D9110 |
|
50 |
50 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
40 |
29 |
$319.00 |
| D1999 |
|
40 |
38 |
$0.00 |