| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,864 |
298 |
$42K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
226 |
112 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
419 |
145 |
$24K |
| D1206 |
Topical application of fluoride varnish |
1,214 |
1,159 |
$22K |
| D1120 |
Prophylaxis - child |
748 |
738 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
379 |
116 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
330 |
133 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
776 |
756 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
241 |
230 |
$9K |
| D0240 |
|
519 |
341 |
$8K |
| D1330 |
|
945 |
933 |
$7K |
| D1110 |
Prophylaxis - adult |
191 |
188 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
276 |
272 |
$5K |
| D0272 |
Bitewings - two radiographic images |
376 |
368 |
$5K |
| D1310 |
|
604 |
597 |
$4K |
| D0330 |
Panoramic radiographic image |
132 |
126 |
$4K |
| D0603 |
|
848 |
835 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
212 |
127 |
$2K |
| D0274 |
Bitewings - four radiographic images |
98 |
93 |
$2K |
| D1354 |
|
55 |
18 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
211 |
184 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$328.47 |