| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
30,797 |
5,132 |
$919K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
5,711 |
2,903 |
$531K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,069 |
2,220 |
$454K |
| D1120 |
Prophylaxis - child |
9,234 |
8,172 |
$353K |
| D1110 |
Prophylaxis - adult |
6,643 |
5,904 |
$351K |
| D0330 |
Panoramic radiographic image |
5,502 |
4,974 |
$350K |
| D0120 |
Periodic oral evaluation - established patient |
12,633 |
11,102 |
$311K |
| D1208 |
Topical application of fluoride, excluding varnish |
15,140 |
13,387 |
$309K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,937 |
892 |
$233K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,876 |
468 |
$225K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,473 |
3,851 |
$208K |
| D1354 |
|
3,421 |
815 |
$190K |
| D0220 |
Intraoral - periapical first radiographic image |
10,980 |
9,641 |
$184K |
| D0140 |
Limited oral evaluation - problem focused |
4,629 |
4,240 |
$164K |
| D0210 |
Intraoral - complete series of radiographic images |
2,202 |
1,969 |
$161K |
| D0230 |
Intraoral - periapical each additional radiographic image |
14,774 |
7,240 |
$148K |
| D1320 |
|
3,589 |
3,093 |
$99K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,612 |
2,376 |
$90K |
| D9310 |
|
1,838 |
1,637 |
$86K |
| D0274 |
Bitewings - four radiographic images |
2,232 |
2,058 |
$84K |
| D0272 |
Bitewings - two radiographic images |
3,223 |
2,784 |
$80K |
| D2740 |
Crown - porcelain/ceramic |
165 |
73 |
$80K |
| D2950 |
|
495 |
311 |
$72K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
75 |
26 |
$47K |
| D9630 |
|
987 |
964 |
$16K |
| D2330 |
|
128 |
82 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
30 |
25 |
$5K |
| D0350 |
|
213 |
199 |
$4K |
| D4341 |
|
25 |
13 |
$4K |
| D2332 |
|
23 |
13 |
$3K |
| D0340 |
|
49 |
42 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
16 |
13 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
96 |
92 |
$3K |
| D1353 |
|
126 |
29 |
$874.50 |