| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
4,204 |
599 |
$95K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
784 |
273 |
$55K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
568 |
198 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,293 |
1,224 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,363 |
1,293 |
$22K |
| D1110 |
Prophylaxis - adult |
567 |
537 |
$21K |
| D1120 |
Prophylaxis - child |
737 |
692 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,532 |
1,419 |
$18K |
| D0274 |
Bitewings - four radiographic images |
567 |
539 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,594 |
1,137 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
106 |
48 |
$9K |
| D0272 |
Bitewings - two radiographic images |
298 |
281 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
230 |
208 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
143 |
136 |
$4K |
| D0330 |
Panoramic radiographic image |
66 |
61 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
27 |
13 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
29 |
14 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
27 |
13 |
$1K |
| D0240 |
|
66 |
59 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
25 |
$733.75 |