| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
52,921 |
12,476 |
$1.45M |
| D1120 |
Prophylaxis - child |
18,215 |
17,803 |
$604K |
| D0120 |
Periodic oral evaluation - established patient |
25,164 |
24,575 |
$587K |
| D1206 |
Topical application of fluoride varnish |
28,772 |
28,072 |
$542K |
| D1110 |
Prophylaxis - adult |
10,037 |
9,816 |
$456K |
| D0274 |
Bitewings - four radiographic images |
10,089 |
9,899 |
$321K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,651 |
1,432 |
$309K |
| D0272 |
Bitewings - two radiographic images |
12,929 |
12,610 |
$285K |
| D0330 |
Panoramic radiographic image |
5,213 |
5,111 |
$206K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,992 |
1,401 |
$174K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,572 |
1,931 |
$165K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,981 |
1,376 |
$159K |
| D2140 |
|
2,532 |
1,882 |
$138K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,467 |
3,179 |
$100K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
688 |
497 |
$62K |
| D0240 |
|
3,108 |
2,843 |
$56K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,230 |
1,212 |
$38K |
| D7140 |
Extraction, erupted tooth or exposed root |
339 |
235 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
2,196 |
2,135 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,864 |
936 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
705 |
682 |
$22K |
| D2160 |
|
280 |
225 |
$21K |
| D0145 |
Oral evaluation for a patient under three years of age |
314 |
311 |
$10K |
| D7240 |
Removal of impacted tooth - completely bony |
39 |
13 |
$7K |
| D2394 |
|
34 |
32 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
67 |
67 |
$1K |
| D2330 |
|
16 |
13 |
$1K |
| D2331 |
|
13 |
12 |
$1K |
| D0270 |
|
77 |
77 |
$1K |
| D1999 |
|
6,441 |
6,089 |
$0.00 |