| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
25,449 |
5,420 |
$385K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,143 |
2,041 |
$201K |
| D1110 |
Prophylaxis - adult |
4,199 |
4,182 |
$151K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,684 |
1,837 |
$134K |
| D0120 |
Periodic oral evaluation - established patient |
6,630 |
6,617 |
$132K |
| D1120 |
Prophylaxis - child |
4,714 |
4,707 |
$111K |
| D0274 |
Bitewings - four radiographic images |
4,952 |
4,938 |
$94K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,865 |
8,844 |
$84K |
| D0220 |
Intraoral - periapical first radiographic image |
8,857 |
8,802 |
$63K |
| D0145 |
Oral evaluation for a patient under three years of age |
758 |
757 |
$63K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,319 |
2,310 |
$60K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,972 |
8,438 |
$59K |
| D0272 |
Bitewings - two radiographic images |
3,463 |
3,458 |
$45K |
| D0210 |
Intraoral - complete series of radiographic images |
703 |
703 |
$37K |
| D7240 |
Removal of impacted tooth - completely bony |
128 |
41 |
$20K |
| D0330 |
Panoramic radiographic image |
2,506 |
2,496 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
751 |
703 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
68 |
56 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
20 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
138 |
136 |
$2K |
| D7111 |
|
116 |
77 |
$780.31 |
| D9310 |
|
64 |
64 |
$406.00 |
| D3120 |
|
46 |
37 |
$57.34 |
| D0602 |
|
1,058 |
1,058 |
$0.00 |
| D0603 |
|
8,523 |
8,506 |
$0.00 |
| D0601 |
|
23 |
23 |
$0.00 |
| D1999 |
|
65 |
59 |
$0.00 |