| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
19,397 |
3,456 |
$472K |
| D1120 |
Prophylaxis - child |
7,001 |
6,869 |
$285K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,269 |
2,431 |
$278K |
| D1110 |
Prophylaxis - adult |
4,441 |
4,389 |
$217K |
| D1206 |
Topical application of fluoride varnish |
7,202 |
7,069 |
$177K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
6,250 |
6,160 |
$162K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
777 |
375 |
$114K |
| D0120 |
Periodic oral evaluation - established patient |
4,325 |
4,260 |
$109K |
| D0210 |
Intraoral - complete series of radiographic images |
1,638 |
1,616 |
$88K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,357 |
3,324 |
$86K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,379 |
878 |
$82K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
687 |
381 |
$74K |
| D7230 |
|
236 |
133 |
$66K |
| D7240 |
Removal of impacted tooth - completely bony |
177 |
69 |
$52K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
752 |
555 |
$51K |
| D9222 |
|
588 |
554 |
$48K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,933 |
2,725 |
$47K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,382 |
7,279 |
$45K |
| D0274 |
Bitewings - four radiographic images |
3,519 |
3,478 |
$43K |
| D0220 |
Intraoral - periapical first radiographic image |
8,605 |
8,346 |
$43K |
| D7140 |
Extraction, erupted tooth or exposed root |
702 |
445 |
$41K |
| D7250 |
|
355 |
157 |
$33K |
| D0603 |
|
3,742 |
3,672 |
$23K |
| D0272 |
Bitewings - two radiographic images |
3,392 |
3,320 |
$21K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
266 |
196 |
$21K |
| D0601 |
|
1,942 |
1,911 |
$13K |
| D0330 |
Panoramic radiographic image |
553 |
526 |
$10K |
| D9310 |
|
921 |
877 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
408 |
396 |
$7K |
| D0145 |
Oral evaluation for a patient under three years of age |
217 |
215 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
68 |
44 |
$4K |
| D0602 |
|
15 |
15 |
$150.00 |