| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
493 |
476 |
$31K |
| D1351 |
Sealant - per tooth |
766 |
232 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
274 |
205 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
821 |
797 |
$30K |
| D1206 |
Topical application of fluoride varnish |
985 |
957 |
$28K |
| D0330 |
Panoramic radiographic image |
334 |
327 |
$28K |
| D1120 |
Prophylaxis - child |
473 |
461 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
168 |
130 |
$24K |
| D0274 |
Bitewings - four radiographic images |
459 |
448 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
162 |
101 |
$17K |
| D0272 |
Bitewings - two radiographic images |
394 |
385 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
156 |
152 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
43 |
41 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
80 |
78 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
119 |
110 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
134 |
129 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$815.00 |