| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
10,198 |
2,195 |
$294K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,635 |
2,206 |
$278K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,384 |
1,548 |
$271K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
6,325 |
5,230 |
$268K |
| D1120 |
Prophylaxis - child |
5,778 |
5,198 |
$207K |
| D1110 |
Prophylaxis - adult |
3,790 |
3,431 |
$190K |
| D1206 |
Topical application of fluoride varnish |
8,252 |
7,380 |
$165K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,997 |
4,497 |
$161K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,838 |
2,809 |
$109K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,115 |
544 |
$86K |
| D0120 |
Periodic oral evaluation - established patient |
3,263 |
2,960 |
$79K |
| D0330 |
Panoramic radiographic image |
1,518 |
1,389 |
$79K |
| D0220 |
Intraoral - periapical first radiographic image |
4,797 |
4,260 |
$73K |
| D0272 |
Bitewings - two radiographic images |
2,510 |
2,238 |
$62K |
| D0140 |
Limited oral evaluation - problem focused |
1,686 |
1,544 |
$58K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
438 |
133 |
$53K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
187 |
135 |
$28K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
262 |
115 |
$26K |
| D0240 |
|
1,125 |
972 |
$19K |
| D2330 |
|
199 |
85 |
$16K |
| D2332 |
|
125 |
65 |
$14K |
| D2331 |
|
72 |
41 |
$7K |
| D9420 |
|
114 |
113 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
32 |
32 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
85 |
79 |
$2K |