| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
8,335 |
1,432 |
$212K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,011 |
1,044 |
$140K |
| D1120 |
Prophylaxis - child |
3,132 |
3,028 |
$135K |
| D1206 |
Topical application of fluoride varnish |
3,458 |
3,339 |
$91K |
| D1110 |
Prophylaxis - adult |
1,592 |
1,556 |
$73K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,505 |
2,429 |
$67K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
737 |
431 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,444 |
1,405 |
$38K |
| D0210 |
Intraoral - complete series of radiographic images |
497 |
480 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
950 |
933 |
$23K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,243 |
1,116 |
$23K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
197 |
79 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
3,916 |
3,705 |
$20K |
| D0274 |
Bitewings - four radiographic images |
1,391 |
1,361 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,240 |
3,428 |
$18K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
193 |
132 |
$14K |
| D0272 |
Bitewings - two radiographic images |
1,736 |
1,670 |
$13K |
| D0603 |
|
1,224 |
1,177 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
106 |
62 |
$7K |
| D0601 |
|
886 |
863 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
243 |
237 |
$4K |
| D2332 |
|
73 |
47 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
46 |
25 |
$3K |
| D2330 |
|
52 |
31 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
116 |
110 |
$2K |
| D0602 |
|
154 |
146 |
$1K |
| D2331 |
|
21 |
15 |
$1K |
| D0330 |
Panoramic radiographic image |
16 |
15 |
$384.00 |