| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
9,034 |
2,658 |
$878K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,186 |
999 |
$560K |
| D7140 |
Extraction, erupted tooth or exposed root |
7,271 |
1,589 |
$440K |
| D9310 |
|
5,819 |
5,770 |
$408K |
| D7240 |
Removal of impacted tooth - completely bony |
2,414 |
899 |
$318K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
5,660 |
1,555 |
$284K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,111 |
667 |
$230K |
| D7250 |
|
2,237 |
607 |
$208K |
| D0330 |
Panoramic radiographic image |
4,084 |
4,025 |
$156K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,501 |
556 |
$125K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
974 |
344 |
$94K |
| D9222 |
|
1,677 |
1,547 |
$83K |
| D9630 |
|
3,022 |
2,840 |
$49K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,866 |
1,183 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,163 |
1,146 |
$30K |
| D7310 |
|
355 |
126 |
$27K |
| D0240 |
|
2,167 |
1,111 |
$26K |
| D7230 |
|
240 |
163 |
$22K |
| D4355 |
|
206 |
206 |
$18K |
| D2330 |
|
189 |
76 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,296 |
1,289 |
$14K |
| D9612 |
|
567 |
558 |
$13K |
| D1120 |
Prophylaxis - child |
399 |
398 |
$13K |
| D2390 |
|
81 |
30 |
$13K |
| D7220 |
|
142 |
94 |
$10K |
| D1206 |
Topical application of fluoride varnish |
449 |
448 |
$9K |
| D1351 |
Sealant - per tooth |
137 |
52 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
1,318 |
1,066 |
$4K |
| D3120 |
|
145 |
81 |
$3K |
| D9243 |
|
317 |
78 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
85 |
80 |
$2K |
| D0272 |
Bitewings - two radiographic images |
61 |
61 |
$1K |
| D9610 |
|
203 |
198 |
$868.30 |
| D9239 |
|
88 |
78 |
$750.75 |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$0.00 |