| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
11,541 |
2,519 |
$311K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,858 |
1,539 |
$278K |
| D0120 |
Periodic oral evaluation - established patient |
6,223 |
6,173 |
$176K |
| D1120 |
Prophylaxis - child |
4,837 |
4,789 |
$173K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,199 |
1,189 |
$166K |
| D1110 |
Prophylaxis - adult |
2,119 |
2,100 |
$113K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,942 |
6,889 |
$100K |
| D0274 |
Bitewings - four radiographic images |
2,780 |
2,756 |
$93K |
| D0272 |
Bitewings - two radiographic images |
3,314 |
3,290 |
$76K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
424 |
234 |
$57K |
| D0220 |
Intraoral - periapical first radiographic image |
2,897 |
2,851 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
411 |
316 |
$32K |
| D0210 |
Intraoral - complete series of radiographic images |
442 |
439 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,596 |
2,546 |
$29K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,101 |
992 |
$29K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
272 |
190 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
529 |
519 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
389 |
382 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
117 |
85 |
$6K |
| D0240 |
|
116 |
61 |
$1K |
| D1206 |
Topical application of fluoride varnish |
36 |
34 |
$499.80 |
| D0602 |
|
7,685 |
7,553 |
$0.00 |
| D0601 |
|
1,259 |
1,249 |
$0.00 |