| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
11,397 |
2,272 |
$203K |
| D1110 |
Prophylaxis - adult |
4,315 |
4,305 |
$154K |
| D0120 |
Periodic oral evaluation - established patient |
6,571 |
6,558 |
$128K |
| D1120 |
Prophylaxis - child |
4,503 |
4,495 |
$105K |
| D0274 |
Bitewings - four radiographic images |
4,950 |
4,940 |
$98K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,697 |
8,684 |
$83K |
| D0145 |
Oral evaluation for a patient under three years of age |
968 |
965 |
$78K |
| D7240 |
Removal of impacted tooth - completely bony |
408 |
137 |
$72K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,358 |
2,355 |
$59K |
| D0272 |
Bitewings - two radiographic images |
3,216 |
3,211 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
554 |
334 |
$39K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
384 |
138 |
$37K |
| D0220 |
Intraoral - periapical first radiographic image |
4,209 |
4,133 |
$32K |
| D0210 |
Intraoral - complete series of radiographic images |
525 |
521 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,743 |
3,510 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
391 |
226 |
$23K |
| D0330 |
Panoramic radiographic image |
1,822 |
1,820 |
$19K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
417 |
400 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
344 |
338 |
$6K |
| D0350 |
|
25 |
25 |
$137.85 |
| D1999 |
|
114 |
99 |
$0.00 |
| D0602 |
|
3,320 |
3,317 |
$0.00 |
| D0603 |
|
5,725 |
5,708 |
$0.00 |
| D0601 |
|
357 |
357 |
$0.00 |