| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,510 |
294 |
$39K |
| D1120 |
Prophylaxis - child |
1,369 |
1,358 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,497 |
1,486 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
462 |
241 |
$27K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
211 |
76 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
966 |
958 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
282 |
137 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
298 |
167 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
705 |
701 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
361 |
305 |
$14K |
| D0272 |
Bitewings - two radiographic images |
554 |
545 |
$9K |
| D1110 |
Prophylaxis - adult |
194 |
193 |
$8K |
| D0330 |
Panoramic radiographic image |
183 |
180 |
$7K |
| D1330 |
|
692 |
688 |
$4K |
| D0603 |
|
337 |
337 |
$3K |
| D0274 |
Bitewings - four radiographic images |
102 |
101 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
356 |
345 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
240 |
214 |
$2K |
| D1206 |
Topical application of fluoride varnish |
68 |
68 |
$1K |
| D1354 |
|
60 |
40 |
$1K |
| D1310 |
|
106 |
106 |
$1K |
| D0602 |
|
105 |
104 |
$1K |
| D0601 |
|
65 |
64 |
$640.00 |