| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
24,938 |
5,778 |
$663K |
| D0120 |
Periodic oral evaluation - established patient |
13,654 |
13,478 |
$386K |
| D1120 |
Prophylaxis - child |
10,682 |
10,546 |
$383K |
| D0145 |
Oral evaluation for a patient under three years of age |
2,631 |
2,606 |
$364K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,683 |
2,284 |
$351K |
| D0230 |
Intraoral - periapical each additional radiographic image |
20,665 |
12,985 |
$219K |
| D1208 |
Topical application of fluoride, excluding varnish |
14,740 |
14,535 |
$212K |
| D1110 |
Prophylaxis - adult |
3,803 |
3,738 |
$202K |
| D0272 |
Bitewings - two radiographic images |
8,853 |
8,730 |
$184K |
| D0220 |
Intraoral - periapical first radiographic image |
13,928 |
13,684 |
$166K |
| D0274 |
Bitewings - four radiographic images |
4,543 |
4,465 |
$141K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,468 |
2,256 |
$64K |
| D0350 |
|
3,488 |
3,379 |
$58K |
| D0330 |
Panoramic radiographic image |
574 |
567 |
$22K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
110 |
63 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
461 |
452 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
189 |
124 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
581 |
564 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
80 |
61 |
$8K |
| D1330 |
|
703 |
688 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
94 |
94 |
$5K |
| D9248 |
|
26 |
26 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
14 |
$1K |
| D0160 |
|
13 |
13 |
$194.35 |
| D0603 |
|
18,018 |
17,792 |
$0.00 |
| D1999 |
|
1,401 |
1,314 |
$0.00 |