| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
25,022 |
5,689 |
$675K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
5,473 |
1,999 |
$415K |
| D0145 |
Oral evaluation for a patient under three years of age |
2,882 |
2,862 |
$402K |
| D1120 |
Prophylaxis - child |
9,085 |
9,008 |
$325K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,739 |
1,310 |
$272K |
| D0230 |
Intraoral - periapical each additional radiographic image |
22,519 |
8,953 |
$247K |
| D0120 |
Periodic oral evaluation - established patient |
8,141 |
8,069 |
$231K |
| D0210 |
Intraoral - complete series of radiographic images |
3,354 |
3,317 |
$225K |
| D1208 |
Topical application of fluoride, excluding varnish |
12,271 |
12,166 |
$176K |
| D1110 |
Prophylaxis - adult |
2,936 |
2,910 |
$157K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,594 |
4,534 |
$156K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
890 |
316 |
$127K |
| D0220 |
Intraoral - periapical first radiographic image |
9,639 |
9,504 |
$118K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,504 |
3,400 |
$93K |
| D0272 |
Bitewings - two radiographic images |
3,453 |
3,423 |
$79K |
| D0274 |
Bitewings - four radiographic images |
2,176 |
2,148 |
$73K |
| D0140 |
Limited oral evaluation - problem focused |
150 |
148 |
$3K |
| D7111 |
|
23 |
14 |
$252.34 |
| D0603 |
|
16,289 |
16,176 |
$0.00 |