| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
5,257 |
1,224 |
$127K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,281 |
631 |
$82K |
| D1120 |
Prophylaxis - child |
2,008 |
1,996 |
$62K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,735 |
2,708 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
2,192 |
2,167 |
$45K |
| D1110 |
Prophylaxis - adult |
958 |
954 |
$37K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
371 |
202 |
$36K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
711 |
689 |
$31K |
| D0272 |
Bitewings - two radiographic images |
1,791 |
1,775 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
596 |
366 |
$30K |
| D0330 |
Panoramic radiographic image |
598 |
590 |
$23K |
| D8670 |
Periodic orthodontic treatment visit |
211 |
211 |
$23K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
280 |
165 |
$21K |
| D0274 |
Bitewings - four radiographic images |
664 |
660 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
829 |
827 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
181 |
124 |
$13K |
| D2330 |
|
72 |
45 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
42 |
34 |
$3K |
| D9110 |
|
61 |
60 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
193 |
190 |
$2K |
| D2332 |
|
18 |
13 |
$1K |
| D2331 |
|
18 |
13 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$104.00 |