| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
9,663 |
1,763 |
$242K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,545 |
541 |
$204K |
| D0230 |
Intraoral - periapical each additional radiographic image |
14,293 |
5,011 |
$148K |
| D0120 |
Periodic oral evaluation - established patient |
4,796 |
4,732 |
$132K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,511 |
754 |
$130K |
| D0145 |
Oral evaluation for a patient under three years of age |
914 |
906 |
$124K |
| D1120 |
Prophylaxis - child |
3,467 |
3,424 |
$121K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,675 |
824 |
$114K |
| D1110 |
Prophylaxis - adult |
1,768 |
1,735 |
$92K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,740 |
4,682 |
$67K |
| D0220 |
Intraoral - periapical first radiographic image |
5,481 |
5,303 |
$63K |
| D0274 |
Bitewings - four radiographic images |
1,905 |
1,869 |
$61K |
| D9248 |
|
427 |
417 |
$46K |
| D0272 |
Bitewings - two radiographic images |
1,428 |
1,411 |
$32K |
| D7140 |
Extraction, erupted tooth or exposed root |
594 |
288 |
$30K |
| D0350 |
|
1,628 |
1,550 |
$26K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
323 |
161 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,050 |
1,026 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
777 |
739 |
$24K |
| D0330 |
Panoramic radiographic image |
230 |
224 |
$12K |
| D2330 |
|
137 |
72 |
$9K |
| D2332 |
|
72 |
43 |
$8K |
| D2335 |
|
58 |
25 |
$8K |
| D1206 |
Topical application of fluoride varnish |
403 |
392 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
161 |
156 |
$3K |
| D1330 |
|
12 |
12 |
$94.34 |
| D0603 |
|
6,607 |
6,546 |
$0.00 |
| D0602 |
|
112 |
110 |
$0.00 |
| D0601 |
|
26 |
26 |
$0.00 |