| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
485 |
129 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
365 |
362 |
$10K |
| D1206 |
Topical application of fluoride varnish |
388 |
385 |
$9K |
| D1120 |
Prophylaxis - child |
327 |
323 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
55 |
14 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
117 |
101 |
$4K |
| D0272 |
Bitewings - two radiographic images |
261 |
259 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
55 |
25 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
514 |
312 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
381 |
364 |
$2K |
| D0240 |
|
99 |
98 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
19 |
$2K |
| D1330 |
|
334 |
332 |
$1K |
| D1110 |
Prophylaxis - adult |
37 |
37 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
15 |
$960.00 |
| D0140 |
Limited oral evaluation - problem focused |
79 |
78 |
$847.00 |
| D0274 |
Bitewings - four radiographic images |
33 |
33 |
$528.00 |
| D0603 |
|
175 |
174 |
$174.00 |
| D0602 |
|
145 |
145 |
$145.00 |
| D0601 |
|
32 |
32 |
$32.00 |