| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
29,622 |
5,347 |
$740K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
1,345 |
1,020 |
$563K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
1,174 |
1,064 |
$391K |
| D1110 |
Prophylaxis - adult |
9,348 |
8,945 |
$388K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,188 |
3,042 |
$383K |
| D0274 |
Bitewings - four radiographic images |
9,187 |
8,796 |
$272K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
9,204 |
8,208 |
$257K |
| D0120 |
Periodic oral evaluation - established patient |
11,921 |
11,466 |
$257K |
| D2954 |
|
2,072 |
1,628 |
$217K |
| D1206 |
Topical application of fluoride varnish |
11,355 |
10,907 |
$201K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,512 |
1,277 |
$199K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,420 |
1,606 |
$169K |
| D1120 |
Prophylaxis - child |
5,164 |
4,979 |
$156K |
| D0140 |
Limited oral evaluation - problem focused |
5,257 |
4,741 |
$146K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,703 |
3,488 |
$108K |
| D0220 |
Intraoral - periapical first radiographic image |
8,788 |
8,075 |
$104K |
| D0330 |
Panoramic radiographic image |
2,459 |
2,319 |
$88K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,444 |
4,182 |
$69K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
657 |
447 |
$49K |
| D0272 |
Bitewings - two radiographic images |
2,288 |
2,185 |
$46K |
| D0270 |
|
1,550 |
1,455 |
$20K |
| D4341 |
|
307 |
121 |
$17K |
| D3320 |
|
13 |
13 |
$3K |
| D2940 |
|
14 |
13 |
$360.00 |
| D1999 |
|
89 |
82 |
$0.00 |