| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1354 |
|
43,011 |
8,714 |
$973K |
| D1351 |
Sealant - per tooth |
29,900 |
5,223 |
$704K |
| D1120 |
Prophylaxis - child |
17,892 |
17,055 |
$687K |
| D2940 |
|
10,015 |
3,545 |
$584K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,811 |
1,487 |
$503K |
| D1206 |
Topical application of fluoride varnish |
16,677 |
16,225 |
$356K |
| D0120 |
Periodic oral evaluation - established patient |
11,112 |
10,624 |
$317K |
| D0274 |
Bitewings - four radiographic images |
6,127 |
5,898 |
$210K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,520 |
3,288 |
$187K |
| D1110 |
Prophylaxis - adult |
2,473 |
2,384 |
$132K |
| D0272 |
Bitewings - two radiographic images |
3,676 |
3,524 |
$97K |
| D0330 |
Panoramic radiographic image |
1,878 |
1,747 |
$97K |
| D7140 |
Extraction, erupted tooth or exposed root |
887 |
453 |
$80K |
| D0140 |
Limited oral evaluation - problem focused |
1,431 |
1,304 |
$60K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,258 |
1,085 |
$56K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,266 |
2,807 |
$48K |
| D1330 |
|
7,265 |
6,826 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
305 |
230 |
$35K |
| D9920 |
|
562 |
531 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
292 |
201 |
$23K |
| D0240 |
|
994 |
481 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
511 |
474 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
29 |
29 |
$1K |
| D3120 |
|
66 |
52 |
$849.09 |
| D0270 |
|
13 |
13 |
$246.78 |
| D0230 |
Intraoral - periapical each additional radiographic image |
39 |
14 |
$224.00 |
| D9986 |
|
72 |
70 |
$0.00 |
| D0601 |
|
1,351 |
1,304 |
$0.00 |
| D0603 |
|
7,305 |
6,634 |
$0.00 |
| D0602 |
|
262 |
247 |
$0.00 |
| D9995 |
|
55 |
53 |
$0.00 |