| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
22,441 |
3,921 |
$393K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,152 |
1,812 |
$224K |
| D1120 |
Prophylaxis - child |
6,855 |
6,761 |
$175K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,004 |
1,765 |
$171K |
| D0120 |
Periodic oral evaluation - established patient |
7,083 |
6,954 |
$148K |
| D1110 |
Prophylaxis - adult |
3,872 |
3,822 |
$142K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,271 |
1,242 |
$114K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,736 |
3,682 |
$98K |
| D0274 |
Bitewings - four radiographic images |
4,418 |
4,357 |
$83K |
| D0220 |
Intraoral - periapical first radiographic image |
10,304 |
10,069 |
$78K |
| D0272 |
Bitewings - two radiographic images |
5,073 |
5,008 |
$72K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,877 |
9,406 |
$67K |
| D0210 |
Intraoral - complete series of radiographic images |
942 |
936 |
$58K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
536 |
246 |
$58K |
| D1206 |
Topical application of fluoride varnish |
5,336 |
5,249 |
$53K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,047 |
4,988 |
$51K |
| D7240 |
Removal of impacted tooth - completely bony |
219 |
66 |
$41K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,845 |
1,707 |
$35K |
| D0330 |
Panoramic radiographic image |
3,024 |
2,980 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
430 |
410 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
118 |
75 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
59 |
40 |
$5K |
| D0270 |
|
46 |
45 |
$183.33 |
| D7111 |
|
17 |
12 |
$136.78 |
| D0350 |
|
12 |
12 |
$126.82 |
| D1999 |
|
388 |
342 |
$0.00 |
| D0602 |
|
1,647 |
1,622 |
$0.00 |
| D0603 |
|
10,006 |
9,831 |
$0.00 |
| D0601 |
|
403 |
397 |
$0.00 |