| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
4,040 |
666 |
$105K |
| D1120 |
Prophylaxis - child |
3,084 |
2,947 |
$103K |
| D0120 |
Periodic oral evaluation - established patient |
3,545 |
3,394 |
$95K |
| D0145 |
Oral evaluation for a patient under three years of age |
520 |
510 |
$71K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
766 |
406 |
$68K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
388 |
170 |
$52K |
| D1206 |
Topical application of fluoride varnish |
3,489 |
3,326 |
$47K |
| D0272 |
Bitewings - two radiographic images |
2,067 |
1,951 |
$43K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
523 |
345 |
$36K |
| D1110 |
Prophylaxis - adult |
602 |
574 |
$30K |
| D0210 |
Intraoral - complete series of radiographic images |
457 |
446 |
$30K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,099 |
1,057 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
1,990 |
1,848 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,911 |
1,546 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
175 |
164 |
$5K |
| D0274 |
Bitewings - four radiographic images |
172 |
162 |
$5K |
| D0330 |
Panoramic radiographic image |
93 |
87 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
249 |
247 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
31 |
19 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
137 |
127 |
$2K |
| D0603 |
|
4,799 |
4,650 |
$0.00 |
| D1999 |
|
1,607 |
1,447 |
$0.00 |