| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,201 |
359 |
$76K |
| D1120 |
Prophylaxis - child |
1,260 |
1,259 |
$47K |
| D9248 |
|
169 |
169 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,476 |
1,475 |
$44K |
| D1206 |
Topical application of fluoride varnish |
1,796 |
1,792 |
$36K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
229 |
117 |
$35K |
| D1110 |
Prophylaxis - adult |
503 |
502 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
331 |
168 |
$23K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
251 |
135 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
202 |
113 |
$19K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
319 |
317 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
363 |
363 |
$14K |
| D0272 |
Bitewings - two radiographic images |
546 |
546 |
$12K |
| D0274 |
Bitewings - four radiographic images |
278 |
278 |
$9K |
| D2140 |
|
107 |
69 |
$7K |
| D2332 |
|
55 |
33 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
47 |
31 |
$5K |
| D0330 |
Panoramic radiographic image |
96 |
96 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
305 |
304 |
$4K |
| D2330 |
|
26 |
16 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
68 |
44 |
$646.00 |