| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
28,194 |
7,315 |
$770K |
| D0120 |
Periodic oral evaluation - established patient |
22,009 |
21,946 |
$630K |
| D1110 |
Prophylaxis - adult |
10,508 |
10,468 |
$570K |
| D0230 |
Intraoral - periapical each additional radiographic image |
51,679 |
22,551 |
$543K |
| D1120 |
Prophylaxis - child |
13,256 |
13,229 |
$482K |
| D0145 |
Oral evaluation for a patient under three years of age |
3,423 |
3,411 |
$479K |
| D0274 |
Bitewings - four radiographic images |
11,628 |
11,573 |
$390K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,797 |
2,279 |
$378K |
| D1208 |
Topical application of fluoride, excluding varnish |
23,847 |
23,780 |
$348K |
| D0220 |
Intraoral - periapical first radiographic image |
23,423 |
23,256 |
$269K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,995 |
1,731 |
$233K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,568 |
956 |
$226K |
| D0272 |
Bitewings - two radiographic images |
7,213 |
7,200 |
$135K |
| D0210 |
Intraoral - complete series of radiographic images |
1,491 |
1,491 |
$76K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,797 |
1,786 |
$62K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
308 |
249 |
$32K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,035 |
987 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
730 |
716 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
185 |
103 |
$12K |
| D0330 |
Panoramic radiographic image |
3,263 |
3,251 |
$8K |
| D7111 |
|
495 |
353 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
59 |
51 |
$5K |
| D0350 |
|
43 |
42 |
$680.06 |
| D0603 |
|
5,503 |
5,494 |
$0.00 |
| D0601 |
|
20,422 |
20,359 |
$0.00 |
| D0602 |
|
1,243 |
1,243 |
$0.00 |