| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
23,865 |
5,386 |
$461K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,504 |
3,087 |
$365K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,241 |
1,287 |
$324K |
| D1120 |
Prophylaxis - child |
11,512 |
11,434 |
$278K |
| D0120 |
Periodic oral evaluation - established patient |
11,746 |
11,648 |
$241K |
| D1110 |
Prophylaxis - adult |
5,923 |
5,871 |
$216K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,768 |
2,414 |
$198K |
| D1206 |
Topical application of fluoride varnish |
17,288 |
17,155 |
$168K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,928 |
1,908 |
$159K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,936 |
5,897 |
$150K |
| D0274 |
Bitewings - four radiographic images |
7,612 |
7,551 |
$148K |
| D0220 |
Intraoral - periapical first radiographic image |
15,580 |
15,372 |
$115K |
| D0272 |
Bitewings - two radiographic images |
8,675 |
8,627 |
$114K |
| D0230 |
Intraoral - periapical each additional radiographic image |
14,988 |
14,116 |
$100K |
| D0210 |
Intraoral - complete series of radiographic images |
1,493 |
1,493 |
$96K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
5,113 |
4,837 |
$91K |
| D7240 |
Removal of impacted tooth - completely bony |
206 |
59 |
$39K |
| D0330 |
Panoramic radiographic image |
4,401 |
4,372 |
$34K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
405 |
131 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
312 |
189 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
391 |
268 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
828 |
818 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
153 |
152 |
$2K |
| D0350 |
|
224 |
223 |
$2K |
| D0270 |
|
324 |
323 |
$981.61 |
| D7111 |
|
92 |
61 |
$681.86 |
| D2950 |
|
20 |
13 |
$473.00 |
| D0603 |
|
15,890 |
15,843 |
$36.28 |
| D1999 |
|
287 |
243 |
$0.00 |
| D0602 |
|
2,722 |
2,715 |
$0.00 |
| D0601 |
|
652 |
651 |
$0.00 |