| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,409 |
547 |
$75K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
606 |
374 |
$67K |
| D0120 |
Periodic oral evaluation - established patient |
2,116 |
2,116 |
$55K |
| D1110 |
Prophylaxis - adult |
984 |
984 |
$52K |
| D1120 |
Prophylaxis - child |
1,330 |
1,330 |
$49K |
| D1206 |
Topical application of fluoride varnish |
2,295 |
2,295 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
357 |
213 |
$40K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
787 |
760 |
$26K |
| D0330 |
Panoramic radiographic image |
345 |
345 |
$21K |
| D0272 |
Bitewings - two radiographic images |
983 |
983 |
$20K |
| D0274 |
Bitewings - four radiographic images |
592 |
592 |
$18K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
53 |
39 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
380 |
378 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
33 |
25 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
90 |
90 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
54 |
54 |
$2K |
| D1354 |
|
38 |
14 |
$570.00 |