| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
6,014 |
940 |
$166K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,252 |
388 |
$136K |
| D1354 |
|
1,533 |
1,011 |
$128K |
| D1120 |
Prophylaxis - child |
3,197 |
3,187 |
$106K |
| D9920 |
|
779 |
764 |
$104K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,940 |
3,929 |
$80K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,119 |
431 |
$79K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,104 |
526 |
$74K |
| D0120 |
Periodic oral evaluation - established patient |
3,101 |
3,092 |
$71K |
| D0272 |
Bitewings - two radiographic images |
2,225 |
2,217 |
$40K |
| D0330 |
Panoramic radiographic image |
909 |
907 |
$39K |
| D1110 |
Prophylaxis - adult |
874 |
872 |
$35K |
| D0140 |
Limited oral evaluation - problem focused |
456 |
454 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,012 |
1,009 |
$25K |
| D1330 |
|
1,442 |
1,441 |
$17K |
| D1310 |
|
1,447 |
1,446 |
$16K |
| D4346 |
|
272 |
272 |
$12K |
| D1206 |
Topical application of fluoride varnish |
372 |
366 |
$7K |
| D0240 |
|
395 |
274 |
$7K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
75 |
43 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
37 |
25 |
$3K |
| D2332 |
|
42 |
26 |
$3K |
| D2335 |
|
24 |
14 |
$2K |
| D9110 |
|
44 |
44 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
12 |
$990.00 |
| D0603 |
|
19 |
19 |
$190.00 |