| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
7,000 |
1,051 |
$185K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,371 |
225 |
$142K |
| D1120 |
Prophylaxis - child |
2,943 |
2,867 |
$96K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,532 |
2,426 |
$75K |
| D1206 |
Topical application of fluoride varnish |
3,320 |
3,221 |
$61K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,716 |
1,685 |
$50K |
| D7140 |
Extraction, erupted tooth or exposed root |
594 |
177 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,657 |
1,623 |
$38K |
| D0220 |
Intraoral - periapical first radiographic image |
2,682 |
2,547 |
$34K |
| D0140 |
Limited oral evaluation - problem focused |
1,141 |
1,016 |
$31K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
854 |
740 |
$27K |
| D0274 |
Bitewings - four radiographic images |
548 |
533 |
$17K |
| D0330 |
Panoramic radiographic image |
445 |
432 |
$15K |
| D0240 |
|
893 |
446 |
$14K |
| D0272 |
Bitewings - two radiographic images |
492 |
481 |
$11K |
| D1110 |
Prophylaxis - adult |
264 |
256 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
93 |
59 |
$7K |
| D2332 |
|
36 |
13 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
12 |
$1K |
| D9920 |
|
48 |
36 |
$780.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
16 |
14 |
$81.20 |
| D1999 |
|
485 |
429 |
$0.00 |