| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
56,618 |
14,823 |
$11.56M |
| D7140 |
Extraction, erupted tooth or exposed root |
32,497 |
13,892 |
$3.00M |
| D1120 |
Prophylaxis - child |
59,696 |
59,684 |
$2.65M |
| D2934 |
|
11,164 |
3,428 |
$2.57M |
| D0230 |
Intraoral - periapical each additional radiographic image |
173,586 |
52,426 |
$2.39M |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17,583 |
9,965 |
$1.76M |
| D1206 |
Topical application of fluoride varnish |
55,488 |
55,477 |
$1.66M |
| D0120 |
Periodic oral evaluation - established patient |
40,165 |
40,159 |
$1.45M |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
10,567 |
6,663 |
$1.39M |
| D0220 |
Intraoral - periapical first radiographic image |
56,706 |
56,273 |
$1.11M |
| D1510 |
|
4,712 |
3,316 |
$1000K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
6,960 |
3,967 |
$925K |
| D1351 |
Sealant - per tooth |
27,396 |
9,179 |
$877K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13,273 |
13,272 |
$827K |
| D0140 |
Limited oral evaluation - problem focused |
8,919 |
8,763 |
$562K |
| D2330 |
|
5,434 |
3,236 |
$496K |
| D9310 |
|
5,629 |
5,627 |
$442K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
4,257 |
695 |
$430K |
| D2390 |
|
1,907 |
761 |
$408K |
| D0272 |
Bitewings - two radiographic images |
12,525 |
12,518 |
$313K |
| D0145 |
Oral evaluation for a patient under three years of age |
7,291 |
7,287 |
$309K |
| D1354 |
|
6,569 |
2,407 |
$191K |
| D2332 |
|
1,235 |
842 |
$168K |
| D2331 |
|
1,434 |
1,079 |
$161K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,427 |
5,426 |
$158K |
| D1517 |
|
424 |
423 |
$133K |
| D9420 |
|
374 |
374 |
$128K |
| D9248 |
|
2,215 |
2,197 |
$122K |
| D9222 |
|
695 |
694 |
$71K |
| D0330 |
Panoramic radiographic image |
928 |
928 |
$61K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
328 |
247 |
$52K |
| D0274 |
Bitewings - four radiographic images |
1,044 |
1,044 |
$40K |
| D2931 |
|
180 |
134 |
$36K |
| D2335 |
|
151 |
110 |
$26K |
| D1110 |
Prophylaxis - adult |
393 |
393 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
388 |
298 |
$14K |
| D2740 |
Crown - porcelain/ceramic |
20 |
15 |
$13K |
| D0270 |
|
739 |
738 |
$11K |
| D7111 |
|
53 |
39 |
$4K |
| D2920 |
|
16 |
13 |
$720.00 |