| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
25,153 |
4,791 |
$452K |
| D1120 |
Prophylaxis - child |
10,800 |
10,752 |
$268K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,570 |
2,264 |
$256K |
| D0145 |
Oral evaluation for a patient under three years of age |
2,833 |
2,815 |
$233K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,312 |
872 |
$232K |
| D0120 |
Periodic oral evaluation - established patient |
10,026 |
9,980 |
$206K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,810 |
1,877 |
$158K |
| D1110 |
Prophylaxis - adult |
4,287 |
4,270 |
$157K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,041 |
5,012 |
$126K |
| D1208 |
Topical application of fluoride, excluding varnish |
12,724 |
12,655 |
$125K |
| D0274 |
Bitewings - four radiographic images |
5,158 |
5,141 |
$98K |
| D0272 |
Bitewings - two radiographic images |
7,252 |
7,216 |
$97K |
| D0210 |
Intraoral - complete series of radiographic images |
1,312 |
1,306 |
$86K |
| D0330 |
Panoramic radiographic image |
4,037 |
4,024 |
$50K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,671 |
2,481 |
$47K |
| D0220 |
Intraoral - periapical first radiographic image |
5,443 |
5,380 |
$40K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,534 |
4,238 |
$30K |
| D7240 |
Removal of impacted tooth - completely bony |
134 |
41 |
$26K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
368 |
100 |
$22K |
| D1206 |
Topical application of fluoride varnish |
1,962 |
1,960 |
$20K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
183 |
144 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
256 |
147 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
457 |
452 |
$7K |
| D2934 |
|
30 |
12 |
$3K |
| D0350 |
|
192 |
192 |
$1K |
| D7111 |
|
56 |
38 |
$446.60 |
| D9310 |
|
40 |
38 |
$240.57 |
| D0270 |
|
12 |
12 |
$56.95 |
| D1999 |
|
657 |
578 |
$0.00 |
| D0603 |
|
15,537 |
15,309 |
$0.00 |
| D0602 |
|
1,700 |
1,676 |
$0.00 |
| D0601 |
|
466 |
466 |
$0.00 |