| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,971 |
1,009 |
$199K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
559 |
328 |
$190K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,182 |
415 |
$106K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,139 |
457 |
$106K |
| D7140 |
Extraction, erupted tooth or exposed root |
972 |
453 |
$83K |
| D0330 |
Panoramic radiographic image |
1,233 |
1,233 |
$71K |
| D9110 |
|
1,199 |
1,193 |
$54K |
| D1120 |
Prophylaxis - child |
1,798 |
1,798 |
$54K |
| D2933 |
|
292 |
104 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,299 |
1,299 |
$49K |
| D1206 |
Topical application of fluoride varnish |
2,444 |
2,444 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,204 |
1,204 |
$32K |
| D3240 |
|
175 |
114 |
$32K |
| D1110 |
Prophylaxis - adult |
653 |
653 |
$31K |
| D1330 |
|
2,448 |
2,448 |
$12K |
| D0272 |
Bitewings - two radiographic images |
494 |
494 |
$12K |
| D0603 |
|
437 |
437 |
$4K |
| D9420 |
|
168 |
168 |
$0.00 |