| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9248 |
|
5,059 |
4,908 |
$1.34M |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
6,930 |
3,528 |
$940K |
| D1351 |
Sealant - per tooth |
24,548 |
4,826 |
$858K |
| D1120 |
Prophylaxis - child |
21,388 |
21,349 |
$839K |
| D0120 |
Periodic oral evaluation - established patient |
26,109 |
26,040 |
$833K |
| D1206 |
Topical application of fluoride varnish |
30,699 |
30,600 |
$688K |
| D1110 |
Prophylaxis - adult |
10,631 |
10,595 |
$615K |
| D7140 |
Extraction, erupted tooth or exposed root |
7,417 |
3,789 |
$598K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,077 |
3,042 |
$570K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
4,361 |
2,795 |
$364K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
6,360 |
6,219 |
$334K |
| D0272 |
Bitewings - two radiographic images |
10,365 |
10,334 |
$304K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
3,523 |
1,790 |
$291K |
| D8670 |
Periodic orthodontic treatment visit |
882 |
787 |
$261K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
6,067 |
6,063 |
$248K |
| D0274 |
Bitewings - four radiographic images |
6,272 |
6,254 |
$229K |
| D1330 |
|
22,650 |
22,601 |
$181K |
| D2140 |
|
2,239 |
1,340 |
$156K |
| D2332 |
|
1,238 |
807 |
$136K |
| D1310 |
|
12,441 |
12,395 |
$128K |
| D1510 |
|
614 |
503 |
$127K |
| D0220 |
Intraoral - periapical first radiographic image |
9,087 |
9,024 |
$117K |
| D0603 |
|
11,059 |
11,052 |
$109K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
758 |
578 |
$106K |
| D1320 |
|
5,318 |
5,311 |
$99K |
| D0330 |
Panoramic radiographic image |
1,775 |
1,769 |
$92K |
| D0140 |
Limited oral evaluation - problem focused |
1,048 |
1,038 |
$67K |
| D2330 |
|
725 |
457 |
$53K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,834 |
1,777 |
$40K |
| D0210 |
Intraoral - complete series of radiographic images |
423 |
423 |
$31K |
| D8080 |
Comprehensive orthodontic treatment of the adolescent dentition |
13 |
13 |
$29K |
| D9110 |
|
573 |
569 |
$23K |
| D2160 |
|
248 |
191 |
$23K |
| D2390 |
|
107 |
54 |
$17K |
| D9920 |
|
114 |
112 |
$14K |
| D0145 |
Oral evaluation for a patient under three years of age |
534 |
531 |
$11K |
| D0270 |
|
585 |
582 |
$9K |
| D0340 |
|
258 |
255 |
$5K |
| D1517 |
|
15 |
15 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
32 |
28 |
$4K |
| D7111 |
|
13 |
12 |
$880.00 |
| D0273 |
|
13 |
13 |
$512.00 |
| D8660 |
|
14 |
14 |
$362.20 |
| D0602 |
|
27 |
27 |
$270.00 |
| D0601 |
|
14 |
14 |
$140.00 |
| D1999 |
|
6,059 |
5,734 |
$39.27 |
| D0350 |
|
13 |
13 |
$0.00 |