| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
25,656 |
4,375 |
$664K |
| D1120 |
Prophylaxis - child |
14,020 |
13,834 |
$486K |
| D0120 |
Periodic oral evaluation - established patient |
17,513 |
17,277 |
$479K |
| D0145 |
Oral evaluation for a patient under three years of age |
2,903 |
2,835 |
$383K |
| D1110 |
Prophylaxis - adult |
5,570 |
5,467 |
$284K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,731 |
1,384 |
$257K |
| D0272 |
Bitewings - two radiographic images |
12,461 |
12,305 |
$246K |
| D0220 |
Intraoral - periapical first radiographic image |
21,690 |
21,223 |
$226K |
| D0230 |
Intraoral - periapical each additional radiographic image |
22,473 |
20,246 |
$218K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,595 |
453 |
$215K |
| D1208 |
Topical application of fluoride, excluding varnish |
12,642 |
12,466 |
$175K |
| D0274 |
Bitewings - four radiographic images |
5,459 |
5,355 |
$148K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,495 |
799 |
$108K |
| D1206 |
Topical application of fluoride varnish |
7,129 |
7,003 |
$100K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,211 |
2,152 |
$71K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,629 |
2,471 |
$65K |
| D0330 |
Panoramic radiographic image |
2,586 |
2,550 |
$56K |
| D9248 |
|
442 |
429 |
$46K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
450 |
206 |
$32K |
| D0210 |
Intraoral - complete series of radiographic images |
430 |
430 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
537 |
230 |
$27K |
| D0350 |
|
1,773 |
1,724 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
194 |
182 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
31 |
18 |
$3K |
| D1330 |
|
237 |
222 |
$2K |
| D2332 |
|
17 |
12 |
$2K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
63 |
25 |
$2K |
| D9222 |
|
28 |
25 |
$877.50 |
| D9420 |
|
14 |
13 |
$469.24 |
| D0603 |
|
25,733 |
25,324 |
$0.00 |
| D0602 |
|
13 |
12 |
$0.00 |