| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
15,884 |
3,539 |
$403K |
| D1120 |
Prophylaxis - child |
5,170 |
4,933 |
$175K |
| D0120 |
Periodic oral evaluation - established patient |
5,461 |
5,219 |
$146K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,077 |
498 |
$138K |
| D1110 |
Prophylaxis - adult |
2,622 |
2,507 |
$132K |
| D0145 |
Oral evaluation for a patient under three years of age |
892 |
845 |
$115K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,198 |
732 |
$107K |
| D0210 |
Intraoral - complete series of radiographic images |
1,527 |
1,433 |
$97K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,171 |
5,837 |
$82K |
| D0274 |
Bitewings - four radiographic images |
2,366 |
2,270 |
$76K |
| D0272 |
Bitewings - two radiographic images |
3,480 |
3,323 |
$76K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,584 |
2,365 |
$62K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,923 |
1,810 |
$61K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
596 |
396 |
$40K |
| D0220 |
Intraoral - periapical first radiographic image |
2,938 |
2,792 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,254 |
2,018 |
$24K |
| D1206 |
Topical application of fluoride varnish |
1,580 |
1,558 |
$23K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
110 |
81 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
93 |
61 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
43 |
39 |
$694.86 |
| D0330 |
Panoramic radiographic image |
18 |
18 |
$510.24 |
| D0603 |
|
8,752 |
8,357 |
$0.00 |
| D0601 |
|
13 |
13 |
$0.00 |