| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
19,924 |
3,605 |
$433K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,454 |
1,046 |
$298K |
| D0120 |
Periodic oral evaluation - established patient |
6,961 |
6,934 |
$197K |
| D1120 |
Prophylaxis - child |
4,710 |
4,692 |
$167K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,125 |
306 |
$161K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,242 |
694 |
$149K |
| D1110 |
Prophylaxis - adult |
2,774 |
2,755 |
$146K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,625 |
8,572 |
$123K |
| D0274 |
Bitewings - four radiographic images |
3,716 |
3,698 |
$113K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,204 |
6,922 |
$100K |
| D0145 |
Oral evaluation for a patient under three years of age |
708 |
699 |
$98K |
| D0220 |
Intraoral - periapical first radiographic image |
7,191 |
7,146 |
$87K |
| D9248 |
|
404 |
402 |
$33K |
| D0272 |
Bitewings - two radiographic images |
1,364 |
1,358 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,018 |
1,012 |
$31K |
| D2330 |
|
388 |
155 |
$27K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
173 |
66 |
$14K |
| D2332 |
|
31 |
14 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
39 |
27 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
55 |
55 |
$1K |
| D0330 |
Panoramic radiographic image |
65 |
65 |
$670.20 |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
15 |
$647.72 |
| D0602 |
|
4,487 |
4,469 |
$0.00 |
| D0603 |
|
3,456 |
3,438 |
$0.00 |
| D0601 |
|
849 |
836 |
$0.00 |