| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9248 |
|
2,175 |
2,062 |
$180K |
| D1120 |
Prophylaxis - child |
6,034 |
6,017 |
$168K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,446 |
563 |
$159K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,098 |
1,220 |
$142K |
| D1206 |
Topical application of fluoride varnish |
7,603 |
7,577 |
$128K |
| D1351 |
Sealant - per tooth |
4,159 |
1,370 |
$110K |
| D9920 |
|
1,902 |
1,817 |
$109K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,718 |
919 |
$94K |
| D0120 |
Periodic oral evaluation - established patient |
5,538 |
5,498 |
$86K |
| D1110 |
Prophylaxis - adult |
2,063 |
2,007 |
$71K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,586 |
2,448 |
$64K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,447 |
2,853 |
$59K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,006 |
1,896 |
$55K |
| D0240 |
|
5,775 |
2,959 |
$54K |
| D0220 |
Intraoral - periapical first radiographic image |
4,126 |
3,909 |
$37K |
| D0330 |
Panoramic radiographic image |
1,117 |
1,092 |
$34K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
624 |
364 |
$30K |
| D0272 |
Bitewings - two radiographic images |
1,403 |
1,402 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
1,171 |
1,116 |
$23K |
| D0274 |
Bitewings - four radiographic images |
998 |
991 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
1,581 |
1,024 |
$16K |
| D0145 |
Oral evaluation for a patient under three years of age |
445 |
444 |
$7K |
| D4346 |
|
96 |
96 |
$3K |
| D9310 |
|
26 |
26 |
$3K |
| D0273 |
|
68 |
66 |
$1K |
| D4355 |
|
16 |
16 |
$1K |
| D2940 |
|
22 |
13 |
$1K |
| D3120 |
|
126 |
100 |
$863.39 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$0.00 |