| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,396 |
502 |
$87K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
706 |
287 |
$52K |
| D1120 |
Prophylaxis - child |
1,327 |
1,294 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,159 |
1,130 |
$37K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
341 |
141 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
455 |
226 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,312 |
1,276 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
375 |
188 |
$18K |
| D0272 |
Bitewings - two radiographic images |
722 |
703 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
138 |
74 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
996 |
966 |
$7K |
| D0603 |
|
758 |
734 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
417 |
408 |
$6K |
| D0601 |
|
464 |
450 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
942 |
905 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
170 |
164 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
43 |
29 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
143 |
139 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
84 |
84 |
$2K |
| D0274 |
Bitewings - four radiographic images |
180 |
174 |
$2K |
| D9920 |
|
190 |
55 |
$2K |
| D1110 |
Prophylaxis - adult |
13 |
12 |
$394.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$118.50 |