| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,524 |
758 |
$89K |
| D0120 |
Periodic oral evaluation - established patient |
2,821 |
2,733 |
$77K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
518 |
185 |
$70K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,424 |
2,835 |
$69K |
| D1120 |
Prophylaxis - child |
1,973 |
1,912 |
$68K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
658 |
362 |
$61K |
| D0145 |
Oral evaluation for a patient under three years of age |
439 |
432 |
$60K |
| D1110 |
Prophylaxis - adult |
981 |
953 |
$51K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
575 |
350 |
$42K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,947 |
2,852 |
$41K |
| D0220 |
Intraoral - periapical first radiographic image |
3,100 |
2,981 |
$37K |
| D0274 |
Bitewings - four radiographic images |
1,022 |
991 |
$34K |
| D0350 |
|
1,909 |
1,832 |
$33K |
| D9248 |
|
195 |
191 |
$22K |
| D0272 |
Bitewings - two radiographic images |
755 |
737 |
$17K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
536 |
524 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
249 |
115 |
$14K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
147 |
57 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
222 |
218 |
$7K |
| D2332 |
|
18 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
69 |
69 |
$1K |
| D0603 |
|
3,691 |
3,610 |
$0.00 |