| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
40,986 |
10,038 |
$1.17M |
| D1120 |
Prophylaxis - child |
25,157 |
24,914 |
$690K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,275 |
3,726 |
$570K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12,031 |
11,890 |
$531K |
| D0330 |
Panoramic radiographic image |
8,504 |
8,409 |
$495K |
| D0120 |
Periodic oral evaluation - established patient |
17,731 |
17,581 |
$461K |
| D1208 |
Topical application of fluoride, excluding varnish |
20,487 |
20,303 |
$338K |
| D0230 |
Intraoral - periapical each additional radiographic image |
16,313 |
13,692 |
$288K |
| D0272 |
Bitewings - two radiographic images |
15,207 |
15,083 |
$276K |
| D0220 |
Intraoral - periapical first radiographic image |
13,975 |
13,856 |
$212K |
| D1110 |
Prophylaxis - adult |
4,254 |
4,215 |
$162K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,607 |
1,258 |
$131K |
| D1206 |
Topical application of fluoride varnish |
7,799 |
7,717 |
$130K |
| D0274 |
Bitewings - four radiographic images |
3,467 |
3,422 |
$109K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
451 |
357 |
$60K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
483 |
479 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
439 |
435 |
$16K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
89 |
64 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
156 |
117 |
$10K |
| D4355 |
|
57 |
57 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
49 |
38 |
$4K |