| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,608 |
1,733 |
$1.12M |
| D1120 |
Prophylaxis - child |
8,572 |
8,570 |
$375K |
| D1206 |
Topical application of fluoride varnish |
8,526 |
8,524 |
$251K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,568 |
1,180 |
$239K |
| D0120 |
Periodic oral evaluation - established patient |
5,961 |
5,960 |
$213K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,625 |
723 |
$211K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,934 |
1,136 |
$188K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,846 |
4,278 |
$148K |
| D0220 |
Intraoral - periapical first radiographic image |
4,996 |
4,976 |
$96K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
716 |
456 |
$91K |
| D1351 |
Sealant - per tooth |
2,564 |
941 |
$82K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,237 |
1,236 |
$79K |
| D0272 |
Bitewings - two radiographic images |
2,347 |
2,347 |
$61K |
| D0140 |
Limited oral evaluation - problem focused |
946 |
942 |
$58K |
| D0145 |
Oral evaluation for a patient under three years of age |
781 |
781 |
$33K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
275 |
52 |
$25K |
| D9310 |
|
206 |
206 |
$17K |
| D2934 |
|
73 |
25 |
$16K |
| D1354 |
|
503 |
224 |
$15K |
| D2330 |
|
103 |
62 |
$9K |
| D9222 |
|
54 |
53 |
$5K |
| D9248 |
|
106 |
104 |
$5K |
| D1510 |
|
12 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$914.96 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$892.00 |