| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,367 |
824 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,873 |
2,815 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
935 |
488 |
$29K |
| D1120 |
Prophylaxis - child |
1,853 |
1,798 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
1,626 |
1,594 |
$23K |
| D0330 |
Panoramic radiographic image |
819 |
815 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,305 |
1,275 |
$20K |
| D1110 |
Prophylaxis - adult |
1,039 |
1,036 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
398 |
367 |
$12K |
| D0272 |
Bitewings - two radiographic images |
1,509 |
1,473 |
$10K |
| D1330 |
|
2,917 |
2,855 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
318 |
195 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
2,948 |
2,712 |
$7K |
| D0274 |
Bitewings - four radiographic images |
803 |
803 |
$7K |
| D9920 |
|
304 |
256 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,806 |
2,587 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
260 |
120 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
278 |
272 |
$2K |
| D0603 |
|
476 |
456 |
$448.00 |
| D3120 |
|
45 |
27 |
$256.84 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
33 |
16 |
$202.00 |
| D0601 |
|
212 |
197 |
$190.00 |
| D0602 |
|
20 |
16 |
$14.00 |
| D1354 |
|
55 |
13 |
$0.00 |