| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
38,496 |
11,386 |
$1.04M |
| D0120 |
Periodic oral evaluation - established patient |
27,184 |
26,601 |
$637K |
| D1120 |
Prophylaxis - child |
18,373 |
17,978 |
$612K |
| D1206 |
Topical application of fluoride varnish |
29,701 |
29,044 |
$563K |
| D1110 |
Prophylaxis - adult |
11,189 |
10,970 |
$513K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,798 |
3,836 |
$482K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
5,399 |
3,811 |
$422K |
| D0274 |
Bitewings - four radiographic images |
12,703 |
12,445 |
$407K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,538 |
1,433 |
$316K |
| D0272 |
Bitewings - two radiographic images |
14,094 |
13,792 |
$310K |
| D0330 |
Panoramic radiographic image |
5,680 |
5,570 |
$213K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,885 |
3,528 |
$126K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,250 |
2,229 |
$67K |
| D7240 |
Removal of impacted tooth - completely bony |
357 |
111 |
$59K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
652 |
478 |
$56K |
| D0140 |
Limited oral evaluation - problem focused |
1,177 |
1,139 |
$38K |
| D0220 |
Intraoral - periapical first radiographic image |
2,427 |
2,388 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
708 |
581 |
$8K |
| D7230 |
|
64 |
29 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
61 |
42 |
$5K |
| D0240 |
|
130 |
120 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
86 |
85 |
$2K |
| D0251 |
|
27 |
27 |
$612.36 |
| D1999 |
|
7,369 |
6,927 |
$0.00 |
| D0350 |
|
25 |
25 |
$0.00 |