| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
4,483 |
1,379 |
$188K |
| D1120 |
Prophylaxis - child |
4,125 |
4,125 |
$174K |
| D0120 |
Periodic oral evaluation - established patient |
3,956 |
3,955 |
$114K |
| D1206 |
Topical application of fluoride varnish |
3,179 |
3,179 |
$94K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
516 |
263 |
$43K |
| D0220 |
Intraoral - periapical first radiographic image |
2,977 |
2,965 |
$40K |
| D0272 |
Bitewings - two radiographic images |
2,347 |
2,347 |
$39K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,760 |
2,758 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,318 |
1,317 |
$18K |
| D1110 |
Prophylaxis - adult |
304 |
303 |
$17K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
141 |
83 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
565 |
565 |
$9K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
115 |
67 |
$9K |
| D0330 |
Panoramic radiographic image |
201 |
201 |
$8K |
| D0274 |
Bitewings - four radiographic images |
77 |
77 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
27 |
13 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
16 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
24 |
24 |
$336.00 |
| D0240 |
|
18 |
18 |
$290.61 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
16 |
15 |
$0.00 |