| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
8,184 |
1,784 |
$874K |
| D1120 |
Prophylaxis - child |
12,491 |
11,930 |
$402K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
4,549 |
966 |
$361K |
| D0120 |
Periodic oral evaluation - established patient |
12,167 |
11,620 |
$285K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,581 |
1,797 |
$253K |
| D2933 |
|
1,597 |
358 |
$231K |
| D1208 |
Topical application of fluoride, excluding varnish |
11,291 |
10,768 |
$229K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,875 |
1,602 |
$172K |
| D9248 |
|
1,605 |
1,485 |
$118K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,710 |
811 |
$102K |
| D0330 |
Panoramic radiographic image |
2,756 |
2,612 |
$102K |
| D1110 |
Prophylaxis - adult |
2,415 |
2,297 |
$99K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,807 |
3,551 |
$97K |
| D0272 |
Bitewings - two radiographic images |
6,038 |
5,752 |
$96K |
| D7240 |
Removal of impacted tooth - completely bony |
383 |
112 |
$93K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,218 |
3,078 |
$89K |
| D1351 |
Sealant - per tooth |
2,403 |
833 |
$72K |
| D1206 |
Topical application of fluoride varnish |
3,227 |
3,089 |
$64K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
681 |
400 |
$53K |
| D9222 |
|
473 |
444 |
$39K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
350 |
206 |
$29K |
| D2332 |
|
209 |
103 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
746 |
705 |
$16K |
| D7230 |
|
73 |
30 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,340 |
1,263 |
$15K |
| D9610 |
|
483 |
454 |
$11K |
| D0274 |
Bitewings - four radiographic images |
380 |
354 |
$9K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
53 |
16 |
$7K |
| D1510 |
|
50 |
39 |
$6K |
| D9420 |
|
970 |
910 |
$240.00 |
| D1999 |
|
17 |
16 |
$0.00 |