| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
823 |
174 |
$13K |
| D1120 |
Prophylaxis - child |
513 |
496 |
$10K |
| D0240 |
|
1,005 |
486 |
$10K |
| D1206 |
Topical application of fluoride varnish |
636 |
612 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
508 |
491 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
179 |
162 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
787 |
256 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
51 |
31 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
70 |
50 |
$4K |
| D0274 |
Bitewings - four radiographic images |
212 |
203 |
$3K |
| D1110 |
Prophylaxis - adult |
132 |
124 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
79 |
76 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
127 |
120 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
60 |
28 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
290 |
277 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
14 |
$743.79 |
| D0140 |
Limited oral evaluation - problem focused |
27 |
24 |
$418.25 |
| D1330 |
|
121 |
114 |
$0.00 |