| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1354 |
|
1,748 |
1,056 |
$126K |
| D1351 |
Sealant - per tooth |
3,477 |
510 |
$99K |
| D9920 |
|
721 |
698 |
$87K |
| D1120 |
Prophylaxis - child |
1,322 |
1,319 |
$43K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
289 |
163 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,701 |
1,698 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
482 |
228 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,124 |
1,124 |
$32K |
| D0140 |
Limited oral evaluation - problem focused |
385 |
383 |
$22K |
| D7140 |
Extraction, erupted tooth or exposed root |
257 |
121 |
$21K |
| D0330 |
Panoramic radiographic image |
377 |
375 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
410 |
407 |
$16K |
| D0272 |
Bitewings - two radiographic images |
849 |
847 |
$15K |
| D1310 |
|
1,361 |
1,358 |
$15K |
| D1330 |
|
1,291 |
1,288 |
$14K |
| D1110 |
Prophylaxis - adult |
285 |
285 |
$11K |
| D4346 |
|
199 |
199 |
$9K |
| D1206 |
Topical application of fluoride varnish |
415 |
397 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
34 |
25 |
$3K |
| D0603 |
|
153 |
152 |
$1K |
| D0240 |
|
43 |
43 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$880.00 |