| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
4,579 |
993 |
$123K |
| D0145 |
Oral evaluation for a patient under three years of age |
688 |
685 |
$96K |
| D0120 |
Periodic oral evaluation - established patient |
3,394 |
3,351 |
$96K |
| D1120 |
Prophylaxis - child |
2,313 |
2,292 |
$83K |
| D0240 |
|
6,788 |
3,250 |
$61K |
| D1110 |
Prophylaxis - adult |
1,129 |
1,118 |
$61K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,663 |
3,626 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
487 |
314 |
$47K |
| D0274 |
Bitewings - four radiographic images |
1,246 |
1,232 |
$40K |
| D0272 |
Bitewings - two radiographic images |
1,720 |
1,701 |
$39K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
189 |
105 |
$28K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
186 |
103 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
151 |
87 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
568 |
554 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
119 |
119 |
$4K |
| D0330 |
Panoramic radiographic image |
49 |
49 |
$987.01 |
| D0140 |
Limited oral evaluation - problem focused |
31 |
29 |
$563.40 |
| D0230 |
Intraoral - periapical each additional radiographic image |
40 |
24 |
$390.88 |
| D1330 |
|
160 |
160 |
$49.75 |
| D0601 |
|
3,281 |
3,253 |
$22.05 |
| D0602 |
|
585 |
583 |
$9.04 |
| D0603 |
|
238 |
234 |
$0.00 |