| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
19,489 |
3,977 |
$528K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,034 |
1,347 |
$434K |
| D0120 |
Periodic oral evaluation - established patient |
14,144 |
14,077 |
$394K |
| D1120 |
Prophylaxis - child |
10,766 |
10,717 |
$379K |
| D0145 |
Oral evaluation for a patient under three years of age |
2,590 |
2,563 |
$360K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,542 |
1,289 |
$240K |
| D1110 |
Prophylaxis - adult |
4,483 |
4,466 |
$237K |
| D1206 |
Topical application of fluoride varnish |
15,002 |
14,936 |
$213K |
| D9248 |
|
1,451 |
1,381 |
$168K |
| D0272 |
Bitewings - two radiographic images |
7,291 |
7,259 |
$166K |
| D0274 |
Bitewings - four radiographic images |
2,862 |
2,847 |
$96K |
| D0210 |
Intraoral - complete series of radiographic images |
1,187 |
1,180 |
$80K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,036 |
705 |
$77K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
822 |
474 |
$66K |
| D0220 |
Intraoral - periapical first radiographic image |
4,446 |
4,363 |
$53K |
| D0350 |
|
2,957 |
2,897 |
$48K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,629 |
1,595 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,112 |
1,110 |
$38K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,991 |
2,663 |
$33K |
| D7140 |
Extraction, erupted tooth or exposed root |
302 |
212 |
$18K |
| D2331 |
|
87 |
54 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
441 |
435 |
$8K |
| D0330 |
Panoramic radiographic image |
77 |
77 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
109 |
109 |
$2K |
| D9310 |
|
13 |
12 |
$160.38 |
| D0603 |
|
18,259 |
18,153 |
$0.00 |