| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9248 |
|
3,641 |
3,548 |
$996K |
| D1351 |
Sealant - per tooth |
23,590 |
5,988 |
$904K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
8,221 |
4,590 |
$878K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,034 |
2,683 |
$860K |
| D1120 |
Prophylaxis - child |
17,086 |
17,056 |
$715K |
| D1206 |
Topical application of fluoride varnish |
26,957 |
25,912 |
$700K |
| D0120 |
Periodic oral evaluation - established patient |
18,883 |
18,838 |
$682K |
| D1110 |
Prophylaxis - adult |
8,038 |
8,009 |
$485K |
| D7140 |
Extraction, erupted tooth or exposed root |
4,289 |
2,331 |
$457K |
| D8670 |
Periodic orthodontic treatment visit |
1,063 |
998 |
$340K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
5,190 |
4,980 |
$323K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,560 |
2,484 |
$316K |
| D0272 |
Bitewings - two radiographic images |
9,401 |
9,376 |
$304K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,711 |
5,693 |
$240K |
| D0274 |
Bitewings - four radiographic images |
5,320 |
5,300 |
$229K |
| D8080 |
Comprehensive orthodontic treatment of the adolescent dentition |
169 |
169 |
$215K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,497 |
1,074 |
$179K |
| D0330 |
Panoramic radiographic image |
2,907 |
2,899 |
$175K |
| D0220 |
Intraoral - periapical first radiographic image |
11,874 |
11,711 |
$158K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,378 |
8,260 |
$151K |
| D0210 |
Intraoral - complete series of radiographic images |
1,704 |
1,701 |
$125K |
| D1330 |
|
18,091 |
18,048 |
$125K |
| D1310 |
|
18,057 |
18,011 |
$124K |
| D0140 |
Limited oral evaluation - problem focused |
1,929 |
1,901 |
$123K |
| D1320 |
|
7,200 |
7,186 |
$115K |
| D0603 |
|
11,389 |
11,374 |
$113K |
| D1510 |
|
269 |
226 |
$59K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
293 |
100 |
$55K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
399 |
288 |
$51K |
| D2332 |
|
430 |
295 |
$47K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,248 |
1,246 |
$37K |
| D2330 |
|
358 |
260 |
$30K |
| D2390 |
|
181 |
102 |
$29K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
84 |
83 |
$26K |
| D0340 |
|
773 |
771 |
$15K |
| D2929 |
|
35 |
33 |
$14K |
| D9222 |
|
82 |
81 |
$14K |
| D1354 |
|
410 |
300 |
$12K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
135 |
68 |
$11K |
| D2331 |
|
92 |
65 |
$10K |
| D2335 |
|
42 |
26 |
$5K |
| D0270 |
|
210 |
201 |
$4K |
| D9110 |
|
78 |
78 |
$4K |
| D7111 |
|
43 |
43 |
$2K |
| D4346 |
|
17 |
17 |
$1K |
| D2991 |
|
27 |
19 |
$794.88 |