| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
9,662 |
2,144 |
$294K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,994 |
807 |
$291K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,025 |
1,402 |
$288K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,338 |
1,753 |
$258K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,948 |
957 |
$234K |
| D1120 |
Prophylaxis - child |
5,655 |
5,287 |
$231K |
| D1206 |
Topical application of fluoride varnish |
7,436 |
6,910 |
$175K |
| D0120 |
Periodic oral evaluation - established patient |
6,519 |
6,057 |
$168K |
| D1110 |
Prophylaxis - adult |
1,807 |
1,685 |
$100K |
| D9920 |
|
1,698 |
1,390 |
$92K |
| D0272 |
Bitewings - two radiographic images |
3,204 |
2,987 |
$77K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,176 |
1,099 |
$56K |
| D0330 |
Panoramic radiographic image |
772 |
734 |
$46K |
| D1510 |
|
248 |
176 |
$40K |
| D2332 |
|
357 |
210 |
$37K |
| D0240 |
|
2,418 |
1,118 |
$32K |
| D2390 |
|
177 |
68 |
$29K |
| D0274 |
Bitewings - four radiographic images |
786 |
744 |
$27K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
229 |
134 |
$25K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
198 |
119 |
$24K |
| D2330 |
|
335 |
201 |
$23K |
| D2335 |
|
183 |
75 |
$21K |
| D2331 |
|
183 |
112 |
$14K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
215 |
104 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
268 |
240 |
$8K |
| D1354 |
|
118 |
36 |
$6K |
| D2140 |
|
104 |
72 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
304 |
262 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
51 |
40 |
$2K |
| D2160 |
|
17 |
13 |
$814.69 |
| D2920 |
|
17 |
14 |
$757.51 |