| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
6,230 |
1,234 |
$154K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,129 |
1,116 |
$154K |
| D1120 |
Prophylaxis - child |
4,150 |
3,960 |
$139K |
| D0120 |
Periodic oral evaluation - established patient |
4,926 |
4,665 |
$130K |
| D1110 |
Prophylaxis - adult |
1,409 |
1,323 |
$67K |
| D0220 |
Intraoral - periapical first radiographic image |
5,873 |
5,506 |
$65K |
| D0272 |
Bitewings - two radiographic images |
3,001 |
2,860 |
$64K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,214 |
4,000 |
$56K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,468 |
5,127 |
$55K |
| D0274 |
Bitewings - four radiographic images |
1,839 |
1,733 |
$55K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,060 |
932 |
$26K |
| D1206 |
Topical application of fluoride varnish |
1,443 |
1,364 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
423 |
401 |
$13K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
91 |
40 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
145 |
97 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
124 |
67 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
22 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
109 |
100 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
12 |
$827.85 |
| D0140 |
Limited oral evaluation - problem focused |
41 |
41 |
$724.90 |
| D0603 |
|
6,833 |
6,660 |
$0.00 |
| D0602 |
|
248 |
247 |
$0.00 |
| D9986 |
|
14 |
14 |
$0.00 |
| D1999 |
|
115 |
109 |
$0.00 |