| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
27,645 |
5,912 |
$531K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,461 |
1,010 |
$464K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
6,002 |
3,606 |
$436K |
| D1120 |
Prophylaxis - child |
16,032 |
15,961 |
$406K |
| D0120 |
Periodic oral evaluation - established patient |
16,992 |
16,915 |
$360K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
5,249 |
3,465 |
$293K |
| D1110 |
Prophylaxis - adult |
7,460 |
7,405 |
$285K |
| D1208 |
Topical application of fluoride, excluding varnish |
23,365 |
23,239 |
$237K |
| D0145 |
Oral evaluation for a patient under three years of age |
2,707 |
2,676 |
$235K |
| D7240 |
Removal of impacted tooth - completely bony |
981 |
314 |
$181K |
| D0272 |
Bitewings - two radiographic images |
12,301 |
12,245 |
$172K |
| D0274 |
Bitewings - four radiographic images |
8,269 |
8,214 |
$169K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
6,607 |
6,513 |
$167K |
| D0210 |
Intraoral - complete series of radiographic images |
1,890 |
1,886 |
$126K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,446 |
444 |
$82K |
| D0220 |
Intraoral - periapical first radiographic image |
9,640 |
9,550 |
$74K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,561 |
8,199 |
$60K |
| D0330 |
Panoramic radiographic image |
4,983 |
4,931 |
$52K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,683 |
2,430 |
$52K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
431 |
312 |
$32K |
| D7140 |
Extraction, erupted tooth or exposed root |
693 |
465 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
1,218 |
1,193 |
$16K |
| D2934 |
|
81 |
27 |
$8K |
| D2330 |
|
53 |
28 |
$3K |
| D7230 |
|
22 |
14 |
$3K |
| D0350 |
|
433 |
429 |
$2K |
| D1206 |
Topical application of fluoride varnish |
187 |
184 |
$2K |
| D7111 |
|
62 |
36 |
$442.99 |
| D0270 |
|
34 |
33 |
$128.45 |
| D3120 |
|
33 |
30 |
$57.34 |
| D0601 |
|
1,733 |
1,724 |
$0.00 |
| D0603 |
|
20,837 |
20,785 |
$0.00 |
| D0602 |
|
3,417 |
3,412 |
$0.00 |
| D1999 |
|
614 |
504 |
$0.00 |