| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
13,714 |
3,898 |
$340K |
| D1120 |
Prophylaxis - child |
10,541 |
10,477 |
$317K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,128 |
659 |
$310K |
| D0120 |
Periodic oral evaluation - established patient |
12,697 |
12,603 |
$255K |
| D1208 |
Topical application of fluoride, excluding varnish |
13,574 |
13,485 |
$252K |
| D1110 |
Prophylaxis - adult |
3,797 |
3,763 |
$137K |
| D0272 |
Bitewings - two radiographic images |
7,952 |
7,899 |
$128K |
| D9920 |
|
689 |
683 |
$86K |
| D0330 |
Panoramic radiographic image |
2,315 |
2,301 |
$86K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,525 |
1,116 |
$84K |
| D0274 |
Bitewings - four radiographic images |
2,811 |
2,784 |
$77K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,754 |
1,706 |
$77K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,130 |
546 |
$73K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
150 |
150 |
$60K |
| D1310 |
|
5,279 |
5,266 |
$57K |
| D1330 |
|
5,200 |
5,187 |
$57K |
| D2140 |
|
1,203 |
900 |
$54K |
| D0220 |
Intraoral - periapical first radiographic image |
4,888 |
4,847 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,837 |
1,829 |
$37K |
| D0240 |
|
2,068 |
1,771 |
$35K |
| D2160 |
|
364 |
275 |
$24K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
264 |
152 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
376 |
292 |
$19K |
| D9222 |
|
150 |
150 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
648 |
582 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
88 |
78 |
$5K |
| D9110 |
|
157 |
154 |
$5K |
| D1320 |
|
506 |
501 |
$0.00 |
| D1999 |
|
247 |
245 |
$0.00 |