| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,961 |
1,915 |
$635K |
| D1120 |
Prophylaxis - child |
16,051 |
15,861 |
$506K |
| D0120 |
Periodic oral evaluation - established patient |
19,817 |
19,617 |
$390K |
| D1206 |
Topical application of fluoride varnish |
18,321 |
18,196 |
$327K |
| D1110 |
Prophylaxis - adult |
6,444 |
6,395 |
$267K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,156 |
1,621 |
$151K |
| D0272 |
Bitewings - two radiographic images |
6,691 |
6,577 |
$148K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,475 |
4,170 |
$142K |
| D1351 |
Sealant - per tooth |
5,591 |
1,563 |
$142K |
| D8670 |
Periodic orthodontic treatment visit |
307 |
302 |
$107K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,447 |
927 |
$103K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,150 |
4,049 |
$92K |
| D0330 |
Panoramic radiographic image |
1,604 |
1,581 |
$90K |
| D0274 |
Bitewings - four radiographic images |
3,839 |
3,811 |
$90K |
| D0210 |
Intraoral - complete series of radiographic images |
2,330 |
2,201 |
$83K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,332 |
2,297 |
$80K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
551 |
432 |
$50K |
| D0140 |
Limited oral evaluation - problem focused |
1,112 |
1,090 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
2,951 |
2,909 |
$22K |
| D9310 |
|
276 |
271 |
$22K |
| D9248 |
|
186 |
180 |
$20K |
| D8080 |
Comprehensive orthodontic treatment of the adolescent dentition |
12 |
12 |
$12K |
| D8660 |
|
42 |
42 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
28 |
12 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,274 |
1,136 |
$2K |
| D0340 |
|
13 |
13 |
$936.26 |
| D0145 |
Oral evaluation for a patient under three years of age |
53 |
53 |
$850.40 |