| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
16,160 |
2,731 |
$401K |
| D1120 |
Prophylaxis - child |
9,977 |
8,904 |
$268K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,961 |
870 |
$212K |
| D0120 |
Periodic oral evaluation - established patient |
8,373 |
7,429 |
$204K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,816 |
255 |
$197K |
| D0230 |
Intraoral - periapical each additional radiographic image |
21,229 |
4,946 |
$193K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,647 |
868 |
$167K |
| D1206 |
Topical application of fluoride varnish |
7,158 |
6,426 |
$159K |
| D0210 |
Intraoral - complete series of radiographic images |
1,498 |
1,318 |
$87K |
| D0220 |
Intraoral - periapical first radiographic image |
5,999 |
5,328 |
$73K |
| D0140 |
Limited oral evaluation - problem focused |
1,646 |
1,387 |
$57K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,062 |
1,796 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,268 |
1,170 |
$46K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,763 |
2,440 |
$39K |
| D0274 |
Bitewings - four radiographic images |
1,013 |
916 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
271 |
162 |
$21K |
| D0330 |
Panoramic radiographic image |
384 |
355 |
$18K |
| D0272 |
Bitewings - two radiographic images |
559 |
526 |
$11K |
| D1110 |
Prophylaxis - adult |
79 |
72 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
28 |
27 |
$978.64 |
| D1310 |
|
20 |
19 |
$0.00 |