| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9248 |
|
680 |
674 |
$177K |
| D0120 |
Periodic oral evaluation - established patient |
3,927 |
3,903 |
$113K |
| D1120 |
Prophylaxis - child |
3,061 |
3,038 |
$112K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
716 |
392 |
$107K |
| D1351 |
Sealant - per tooth |
2,564 |
476 |
$89K |
| D1206 |
Topical application of fluoride varnish |
4,374 |
4,343 |
$87K |
| D1110 |
Prophylaxis - adult |
1,284 |
1,280 |
$71K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
818 |
436 |
$65K |
| D7140 |
Extraction, erupted tooth or exposed root |
749 |
409 |
$52K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
776 |
764 |
$40K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
330 |
221 |
$29K |
| D0272 |
Bitewings - two radiographic images |
1,324 |
1,318 |
$28K |
| D2140 |
|
389 |
239 |
$27K |
| D0274 |
Bitewings - four radiographic images |
683 |
681 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
485 |
485 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
165 |
101 |
$15K |
| D2332 |
|
100 |
73 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
907 |
898 |
$12K |
| D0330 |
Panoramic radiographic image |
185 |
184 |
$10K |
| D1510 |
|
38 |
31 |
$8K |
| D1310 |
|
261 |
261 |
$4K |
| D2330 |
|
40 |
24 |
$3K |
| D9110 |
|
59 |
59 |
$3K |
| D2160 |
|
23 |
16 |
$2K |
| D1330 |
|
175 |
175 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
203 |
133 |
$2K |
| D0270 |
|
43 |
42 |
$697.80 |