| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
4,567 |
976 |
$121K |
| D1120 |
Prophylaxis - child |
3,071 |
3,071 |
$112K |
| D0120 |
Periodic oral evaluation - established patient |
2,820 |
2,820 |
$88K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
556 |
158 |
$72K |
| D0272 |
Bitewings - two radiographic images |
2,647 |
2,647 |
$48K |
| D9420 |
|
135 |
135 |
$47K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,587 |
2,587 |
$45K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
624 |
365 |
$44K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
523 |
523 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
283 |
160 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
347 |
207 |
$20K |
| D1110 |
Prophylaxis - adult |
333 |
333 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
308 |
304 |
$17K |
| D0240 |
|
2,576 |
2,574 |
$14K |
| D9920 |
|
377 |
372 |
$13K |
| D1206 |
Topical application of fluoride varnish |
789 |
789 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
174 |
174 |
$11K |
| D0603 |
|
1,016 |
1,016 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
97 |
77 |
$8K |
| D2933 |
|
44 |
12 |
$7K |
| D0602 |
|
482 |
482 |
$5K |
| D0330 |
Panoramic radiographic image |
65 |
65 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
33 |
16 |
$3K |
| D9999 |
Unspecified adjunctive procedure, by report |
118 |
118 |
$118.00 |