| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,365 |
544 |
$67K |
| D0120 |
Periodic oral evaluation - established patient |
2,703 |
2,699 |
$62K |
| D1120 |
Prophylaxis - child |
2,057 |
2,053 |
$54K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
903 |
607 |
$54K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,389 |
2,387 |
$46K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,306 |
1,188 |
$44K |
| D0272 |
Bitewings - two radiographic images |
2,261 |
2,259 |
$41K |
| D1110 |
Prophylaxis - adult |
951 |
951 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
631 |
423 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
401 |
249 |
$20K |
| D0603 |
|
1,988 |
1,985 |
$20K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
247 |
153 |
$19K |
| D1330 |
|
2,130 |
2,127 |
$11K |
| D1206 |
Topical application of fluoride varnish |
475 |
473 |
$10K |
| D0330 |
Panoramic radiographic image |
169 |
169 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
185 |
184 |
$4K |
| D0274 |
Bitewings - four radiographic images |
96 |
96 |
$3K |
| D0240 |
|
136 |
92 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
249 |
248 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
107 |
106 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
145 |
145 |
$1K |
| D0602 |
|
54 |
54 |
$540.00 |
| D0601 |
|
26 |
26 |
$260.00 |