| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
12,275 |
2,933 |
$324K |
| D0145 |
Oral evaluation for a patient under three years of age |
2,066 |
2,049 |
$286K |
| D0120 |
Periodic oral evaluation - established patient |
8,090 |
8,019 |
$229K |
| D1120 |
Prophylaxis - child |
5,692 |
5,630 |
$205K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,893 |
961 |
$181K |
| D1110 |
Prophylaxis - adult |
3,108 |
3,085 |
$167K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12,109 |
7,394 |
$134K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,776 |
8,685 |
$126K |
| D0274 |
Bitewings - four radiographic images |
3,114 |
3,075 |
$102K |
| D0220 |
Intraoral - periapical first radiographic image |
7,920 |
7,784 |
$97K |
| D0272 |
Bitewings - two radiographic images |
3,294 |
3,259 |
$74K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
507 |
237 |
$72K |
| D0210 |
Intraoral - complete series of radiographic images |
919 |
917 |
$63K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,043 |
1,883 |
$53K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
468 |
266 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
637 |
613 |
$21K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
200 |
139 |
$20K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
160 |
77 |
$13K |
| D0330 |
Panoramic radiographic image |
285 |
273 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
229 |
225 |
$4K |
| D7111 |
|
182 |
137 |
$2K |
| D9248 |
|
16 |
16 |
$2K |
| D2331 |
|
19 |
16 |
$2K |
| D1206 |
Topical application of fluoride varnish |
58 |
57 |
$836.43 |
| D0350 |
|
15 |
15 |
$128.66 |
| D0601 |
|
53 |
52 |
$0.00 |
| D0603 |
|
10,962 |
10,829 |
$0.00 |
| D1330 |
|
228 |
226 |
$0.00 |