| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,744 |
458 |
$58K |
| D1120 |
Prophylaxis - child |
1,437 |
1,430 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
1,783 |
1,778 |
$48K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,964 |
1,957 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
449 |
260 |
$31K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
272 |
103 |
$27K |
| D1110 |
Prophylaxis - adult |
532 |
531 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
252 |
151 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
293 |
187 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
551 |
512 |
$14K |
| D0272 |
Bitewings - two radiographic images |
735 |
731 |
$14K |
| D0330 |
Panoramic radiographic image |
293 |
292 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
144 |
91 |
$12K |
| D0274 |
Bitewings - four radiographic images |
297 |
297 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
168 |
163 |
$5K |
| D1999 |
|
878 |
804 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
118 |
117 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
350 |
339 |
$4K |
| D0603 |
|
253 |
251 |
$3K |
| D0240 |
|
118 |
73 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
156 |
71 |
$1K |
| D0602 |
|
34 |
34 |
$363.00 |