| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
47,661 |
5,901 |
$1.21M |
| D1120 |
Prophylaxis - child |
15,236 |
14,315 |
$475K |
| D0120 |
Periodic oral evaluation - established patient |
20,891 |
19,597 |
$465K |
| D1206 |
Topical application of fluoride varnish |
21,984 |
20,614 |
$402K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,881 |
906 |
$347K |
| D1110 |
Prophylaxis - adult |
6,558 |
6,120 |
$279K |
| D0274 |
Bitewings - four radiographic images |
8,625 |
8,036 |
$262K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,640 |
2,328 |
$260K |
| D0272 |
Bitewings - two radiographic images |
10,629 |
9,984 |
$227K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,327 |
1,041 |
$178K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
5,709 |
4,756 |
$150K |
| D0330 |
Panoramic radiographic image |
3,842 |
3,592 |
$137K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,744 |
1,206 |
$133K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,837 |
3,947 |
$102K |
| D0220 |
Intraoral - periapical first radiographic image |
6,704 |
6,168 |
$83K |
| D1354 |
|
5,098 |
2,129 |
$66K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,000 |
1,870 |
$61K |
| D0140 |
Limited oral evaluation - problem focused |
732 |
687 |
$21K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
18 |
12 |
$1K |
| D0240 |
|
65 |
33 |
$941.97 |
| D3120 |
|
92 |
56 |
$0.00 |
| D1999 |
|
2,268 |
1,986 |
$0.00 |