| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,673 |
577 |
$53K |
| D1120 |
Prophylaxis - child |
1,062 |
1,059 |
$47K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
529 |
290 |
$36K |
| D1206 |
Topical application of fluoride varnish |
1,064 |
1,062 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
973 |
971 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
233 |
156 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
488 |
488 |
$12K |
| D1353 |
|
1,389 |
316 |
$12K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
77 |
53 |
$8K |
| D0272 |
Bitewings - two radiographic images |
522 |
519 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
875 |
871 |
$4K |
| D0603 |
|
537 |
536 |
$4K |
| D0274 |
Bitewings - four radiographic images |
289 |
289 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
800 |
797 |
$2K |
| D1110 |
Prophylaxis - adult |
52 |
52 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
58 |
58 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
29 |
$1K |
| D0601 |
|
164 |
162 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$585.00 |
| D0602 |
|
66 |
63 |
$540.00 |