| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,769 |
2,768 |
$180K |
| D2740 |
Crown - porcelain/ceramic |
371 |
270 |
$175K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,017 |
259 |
$120K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,605 |
850 |
$105K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
886 |
409 |
$104K |
| D0210 |
Intraoral - complete series of radiographic images |
1,842 |
1,842 |
$87K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
812 |
224 |
$79K |
| D4341 |
|
808 |
235 |
$57K |
| D1351 |
Sealant - per tooth |
1,265 |
322 |
$46K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
820 |
486 |
$44K |
| D1120 |
Prophylaxis - child |
870 |
870 |
$42K |
| D7240 |
Removal of impacted tooth - completely bony |
175 |
82 |
$40K |
| D1110 |
Prophylaxis - adult |
453 |
453 |
$39K |
| D7230 |
|
203 |
125 |
$38K |
| D0350 |
|
3,814 |
1,378 |
$36K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
462 |
313 |
$36K |
| D7140 |
Extraction, erupted tooth or exposed root |
533 |
194 |
$30K |
| D1206 |
Topical application of fluoride varnish |
1,477 |
1,477 |
$25K |
| D1510 |
|
102 |
66 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,840 |
899 |
$16K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
26 |
24 |
$12K |
| D0330 |
Panoramic radiographic image |
374 |
374 |
$11K |
| D9430 |
|
334 |
324 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
216 |
216 |
$8K |
| D4910 |
|
103 |
103 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
627 |
613 |
$7K |
| D3320 |
|
19 |
16 |
$7K |
| D2331 |
|
79 |
57 |
$6K |
| D2330 |
|
75 |
46 |
$6K |
| D2332 |
|
56 |
28 |
$4K |
| D4342 |
|
85 |
29 |
$4K |
| D1310 |
|
67 |
65 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
54 |
54 |
$2K |
| D2954 |
|
18 |
15 |
$2K |
| D3221 |
|
14 |
12 |
$882.00 |
| D9248 |
|
19 |
19 |
$630.00 |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$324.00 |