| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
13,556 |
2,074 |
$464K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
854 |
494 |
$177K |
| D1120 |
Prophylaxis - child |
3,148 |
3,146 |
$146K |
| D0120 |
Periodic oral evaluation - established patient |
3,689 |
3,686 |
$139K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,610 |
3,610 |
$100K |
| D7140 |
Extraction, erupted tooth or exposed root |
863 |
440 |
$82K |
| D0330 |
Panoramic radiographic image |
858 |
858 |
$69K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
458 |
318 |
$62K |
| D1110 |
Prophylaxis - adult |
1,024 |
1,024 |
$61K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
271 |
155 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
363 |
259 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
357 |
357 |
$22K |
| D1206 |
Topical application of fluoride varnish |
448 |
447 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
165 |
164 |
$11K |
| D2335 |
|
23 |
13 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
53 |
51 |
$1K |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$690.80 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$408.50 |