| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
24,111 |
4,217 |
$635K |
| D1120 |
Prophylaxis - child |
6,149 |
6,067 |
$192K |
| D1206 |
Topical application of fluoride varnish |
9,909 |
9,566 |
$169K |
| D0120 |
Periodic oral evaluation - established patient |
7,086 |
7,008 |
$156K |
| D1110 |
Prophylaxis - adult |
2,265 |
2,245 |
$95K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,053 |
523 |
$92K |
| D0274 |
Bitewings - four radiographic images |
3,008 |
2,980 |
$90K |
| D0330 |
Panoramic radiographic image |
1,894 |
1,854 |
$86K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,066 |
487 |
$81K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,012 |
523 |
$72K |
| D0272 |
Bitewings - two radiographic images |
3,284 |
3,235 |
$68K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,668 |
1,576 |
$49K |
| D0240 |
|
2,598 |
1,513 |
$46K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,058 |
1,414 |
$43K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
304 |
92 |
$35K |
| D0220 |
Intraoral - periapical first radiographic image |
2,035 |
1,998 |
$26K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
78 |
63 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,531 |
1,441 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
665 |
641 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
483 |
473 |
$15K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
153 |
51 |
$8K |
| D2390 |
|
43 |
15 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
148 |
147 |
$4K |
| D9222 |
|
58 |
56 |
$4K |
| D9219 |
|
194 |
194 |
$4K |
| D9610 |
|
78 |
75 |
$1K |