| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
14,617 |
1,403 |
$405K |
| D0120 |
Periodic oral evaluation - established patient |
9,693 |
9,664 |
$278K |
| D1110 |
Prophylaxis - adult |
3,939 |
3,929 |
$216K |
| D1120 |
Prophylaxis - child |
5,869 |
5,843 |
$214K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,495 |
1,490 |
$211K |
| D1208 |
Topical application of fluoride, excluding varnish |
9,872 |
9,836 |
$144K |
| D0274 |
Bitewings - four radiographic images |
3,933 |
3,923 |
$129K |
| D0272 |
Bitewings - two radiographic images |
5,203 |
5,179 |
$115K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
773 |
219 |
$110K |
| D0220 |
Intraoral - periapical first radiographic image |
5,556 |
5,526 |
$66K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
622 |
322 |
$62K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,420 |
5,341 |
$59K |
| D9248 |
|
476 |
456 |
$56K |
| D0330 |
Panoramic radiographic image |
1,324 |
1,319 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
368 |
368 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
308 |
193 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
326 |
326 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
164 |
161 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
23 |
13 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$459.16 |
| D0603 |
|
3,896 |
3,890 |
$0.00 |
| D0602 |
|
1,952 |
1,944 |
$0.00 |
| D0601 |
|
5,531 |
5,518 |
$0.00 |