| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,900 |
541 |
$74K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
410 |
221 |
$63K |
| D1120 |
Prophylaxis - child |
1,719 |
1,605 |
$53K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,364 |
1,254 |
$45K |
| D1110 |
Prophylaxis - adult |
861 |
805 |
$39K |
| D1206 |
Topical application of fluoride varnish |
1,579 |
1,475 |
$32K |
| D0210 |
Intraoral - complete series of radiographic images |
734 |
686 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
1,361 |
1,298 |
$30K |
| D0272 |
Bitewings - two radiographic images |
1,202 |
1,127 |
$27K |
| D0274 |
Bitewings - four radiographic images |
825 |
764 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
515 |
271 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
856 |
729 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
194 |
107 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
705 |
651 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
852 |
784 |
$9K |
| D2140 |
|
137 |
82 |
$8K |
| D0330 |
Panoramic radiographic image |
242 |
213 |
$8K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
82 |
44 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
733 |
586 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
85 |
81 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
12 |
$1K |
| D7111 |
|
19 |
12 |
$1K |
| D1999 |
|
448 |
364 |
$180.00 |