| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
6,086 |
1,361 |
$805K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
8,720 |
1,637 |
$545K |
| D7140 |
Extraction, erupted tooth or exposed root |
4,243 |
1,374 |
$281K |
| D1120 |
Prophylaxis - child |
7,713 |
7,618 |
$260K |
| D1206 |
Topical application of fluoride varnish |
7,833 |
7,740 |
$165K |
| D9310 |
|
1,679 |
1,661 |
$136K |
| D9222 |
|
1,670 |
1,648 |
$104K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,269 |
3,234 |
$99K |
| D0120 |
Periodic oral evaluation - established patient |
4,728 |
4,668 |
$99K |
| D9630 |
|
4,804 |
4,742 |
$98K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,495 |
3,155 |
$83K |
| D0272 |
Bitewings - two radiographic images |
3,558 |
3,519 |
$71K |
| D9612 |
|
1,694 |
1,639 |
$66K |
| D0240 |
|
4,092 |
2,403 |
$50K |
| D0220 |
Intraoral - periapical first radiographic image |
3,645 |
3,576 |
$40K |
| D1351 |
Sealant - per tooth |
1,163 |
356 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
395 |
220 |
$34K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
399 |
184 |
$29K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
675 |
611 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
916 |
896 |
$23K |
| D0210 |
Intraoral - complete series of radiographic images |
1,861 |
837 |
$10K |
| D0274 |
Bitewings - four radiographic images |
97 |
97 |
$3K |
| D3120 |
|
125 |
74 |
$2K |
| D9995 |
|
29 |
26 |
$1K |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$810.84 |
| D1354 |
|
61 |
31 |
$732.00 |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$660.66 |