| Code | Description | Claims | Beneficiaries | Total Paid |
| D1351 |
Sealant - per tooth |
51,075 |
7,013 |
$1.29M |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
9,312 |
4,873 |
$1.25M |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19,108 |
9,415 |
$1.15M |
| D1120 |
Prophylaxis - child |
36,095 |
28,500 |
$1.05M |
| D1206 |
Topical application of fluoride varnish |
48,462 |
37,142 |
$936K |
| D0120 |
Periodic oral evaluation - established patient |
43,187 |
33,430 |
$853K |
| D7140 |
Extraction, erupted tooth or exposed root |
11,315 |
5,426 |
$802K |
| D1110 |
Prophylaxis - adult |
16,352 |
12,087 |
$675K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
25,282 |
18,406 |
$630K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
10,782 |
5,973 |
$487K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
4,259 |
2,418 |
$399K |
| D0272 |
Bitewings - two radiographic images |
19,459 |
15,209 |
$398K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
10,941 |
8,470 |
$351K |
| D0274 |
Bitewings - four radiographic images |
10,901 |
7,860 |
$310K |
| D0330 |
Panoramic radiographic image |
4,239 |
3,140 |
$199K |
| D0140 |
Limited oral evaluation - problem focused |
6,545 |
5,021 |
$188K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
2,451 |
1,461 |
$174K |
| D0240 |
|
9,911 |
3,909 |
$131K |
| D1510 |
|
960 |
632 |
$128K |
| D8080 |
Comprehensive orthodontic treatment of the adolescent dentition |
35 |
28 |
$113K |
| D9920 |
|
4,467 |
3,226 |
$109K |
| D0220 |
Intraoral - periapical first radiographic image |
9,764 |
7,129 |
$96K |
| D2330 |
|
1,447 |
817 |
$94K |
| D9243 |
|
1,334 |
309 |
$73K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,248 |
2,687 |
$49K |
| D2335 |
|
361 |
164 |
$49K |
| D0210 |
Intraoral - complete series of radiographic images |
1,639 |
1,175 |
$33K |
| D2332 |
|
291 |
146 |
$28K |
| D9239 |
|
392 |
309 |
$24K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
88 |
25 |
$15K |
| D2331 |
|
111 |
63 |
$9K |
| D0270 |
|
458 |
391 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,563 |
1,513 |
$5K |
| D1354 |
|
60 |
13 |
$2K |
| D1999 |
|
14,138 |
7,268 |
$930.00 |
| D9310 |
|
875 |
591 |
$0.00 |
| D3120 |
|
238 |
182 |
$0.00 |