| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
7,600 |
7,424 |
$1.03M |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
10,763 |
4,103 |
$1.03M |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
7,118 |
1,429 |
$933K |
| D1351 |
Sealant - per tooth |
35,638 |
8,265 |
$865K |
| D0120 |
Periodic oral evaluation - established patient |
23,911 |
23,105 |
$650K |
| D1120 |
Prophylaxis - child |
18,892 |
18,261 |
$648K |
| D0274 |
Bitewings - four radiographic images |
11,563 |
11,219 |
$378K |
| D1208 |
Topical application of fluoride, excluding varnish |
26,431 |
25,569 |
$366K |
| D1110 |
Prophylaxis - adult |
7,163 |
6,965 |
$362K |
| D0230 |
Intraoral - periapical each additional radiographic image |
30,929 |
25,307 |
$330K |
| D0220 |
Intraoral - periapical first radiographic image |
27,789 |
26,739 |
$327K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
3,627 |
1,048 |
$261K |
| D0272 |
Bitewings - two radiographic images |
10,716 |
10,396 |
$236K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,682 |
1,342 |
$195K |
| D9248 |
|
1,819 |
1,662 |
$192K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,972 |
1,103 |
$86K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,302 |
2,217 |
$75K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,276 |
2,173 |
$57K |
| D0140 |
Limited oral evaluation - problem focused |
1,825 |
1,771 |
$41K |
| D7240 |
Removal of impacted tooth - completely bony |
86 |
24 |
$23K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
211 |
117 |
$19K |
| D0330 |
Panoramic radiographic image |
232 |
218 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
111 |
97 |
$5K |
| D0270 |
|
69 |
69 |
$1K |
| D9243 |
|
32 |
12 |
$1K |
| D9222 |
|
15 |
12 |
$640.58 |
| D9239 |
|
12 |
12 |
$627.44 |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
20 |
12 |
$570.44 |
| D9610 |
|
25 |
24 |
$376.32 |
| D0160 |
|
27 |
24 |
$343.85 |
| D3120 |
|
43 |
24 |
$57.34 |
| D0603 |
|
34,335 |
33,595 |
$0.00 |