| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,871 |
991 |
$96K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,381 |
808 |
$88K |
| D1120 |
Prophylaxis - child |
2,434 |
2,431 |
$88K |
| D0120 |
Periodic oral evaluation - established patient |
3,527 |
3,523 |
$72K |
| D1206 |
Topical application of fluoride varnish |
3,267 |
3,265 |
$58K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
456 |
140 |
$50K |
| D1110 |
Prophylaxis - adult |
1,333 |
1,333 |
$49K |
| D7140 |
Extraction, erupted tooth or exposed root |
654 |
348 |
$48K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
788 |
564 |
$42K |
| D0274 |
Bitewings - four radiographic images |
941 |
939 |
$26K |
| D0272 |
Bitewings - two radiographic images |
1,333 |
1,331 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
279 |
207 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
714 |
714 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
265 |
239 |
$12K |
| D0330 |
Panoramic radiographic image |
141 |
141 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
646 |
637 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
239 |
238 |
$4K |
| D9110 |
|
61 |
60 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
166 |
144 |
$2K |
| D2332 |
|
24 |
13 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
24 |
24 |
$471.00 |