| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
28,776 |
7,758 |
$680K |
| D1120 |
Prophylaxis - child |
17,643 |
16,406 |
$495K |
| D0120 |
Periodic oral evaluation - established patient |
25,171 |
23,400 |
$479K |
| D1110 |
Prophylaxis - adult |
10,696 |
9,950 |
$452K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
6,554 |
4,197 |
$392K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,492 |
1,335 |
$331K |
| D1206 |
Topical application of fluoride varnish |
16,706 |
15,526 |
$309K |
| D0210 |
Intraoral - complete series of radiographic images |
4,603 |
4,223 |
$275K |
| D1354 |
|
4,192 |
1,323 |
$231K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
8,637 |
7,570 |
$214K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,920 |
2,771 |
$188K |
| D1208 |
Topical application of fluoride, excluding varnish |
9,881 |
9,207 |
$176K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
365 |
325 |
$171K |
| D0140 |
Limited oral evaluation - problem focused |
4,188 |
3,811 |
$131K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,392 |
1,087 |
$116K |
| D0274 |
Bitewings - four radiographic images |
3,792 |
3,525 |
$114K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,364 |
3,127 |
$100K |
| D0272 |
Bitewings - two radiographic images |
5,064 |
4,712 |
$94K |
| D0330 |
Panoramic radiographic image |
1,191 |
1,100 |
$64K |
| D0220 |
Intraoral - periapical first radiographic image |
3,760 |
3,430 |
$41K |
| D7140 |
Extraction, erupted tooth or exposed root |
717 |
442 |
$35K |
| D7111 |
|
529 |
387 |
$22K |
| D2335 |
|
121 |
95 |
$11K |
| D2931 |
|
114 |
98 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,280 |
925 |
$8K |
| D2330 |
|
32 |
24 |
$2K |
| D1320 |
|
37 |
37 |
$1K |
| D0240 |
|
165 |
99 |
$425.50 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
18 |
12 |
$200.46 |
| D0603 |
|
195 |
195 |
$0.00 |
| D0602 |
|
42 |
42 |
$0.00 |