| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
16,322 |
13,270 |
$8.16M |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,454 |
503 |
$86K |
| D7140 |
Extraction, erupted tooth or exposed root |
4,487 |
1,832 |
$62K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,874 |
1,850 |
$54K |
| D1110 |
Prophylaxis - adult |
5,000 |
4,677 |
$50K |
| D0210 |
Intraoral - complete series of radiographic images |
2,790 |
2,584 |
$42K |
| D0140 |
Limited oral evaluation - problem focused |
4,684 |
4,298 |
$38K |
| D1206 |
Topical application of fluoride varnish |
7,189 |
6,735 |
$35K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
864 |
343 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,800 |
1,168 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
4,091 |
3,828 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,654 |
2,489 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
729 |
502 |
$19K |
| D1120 |
Prophylaxis - child |
2,102 |
1,988 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
4,254 |
3,934 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
922 |
794 |
$13K |
| D0274 |
Bitewings - four radiographic images |
1,828 |
1,728 |
$10K |
| D9420 |
|
103 |
94 |
$9K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
214 |
107 |
$9K |
| D7240 |
Removal of impacted tooth - completely bony |
33 |
13 |
$7K |
| D1351 |
Sealant - per tooth |
949 |
320 |
$6K |
| D9222 |
|
139 |
109 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
724 |
404 |
$5K |
| D2394 |
|
95 |
67 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
59 |
32 |
$3K |
| D0330 |
Panoramic radiographic image |
96 |
69 |
$3K |
| D2940 |
|
58 |
30 |
$1K |
| D0272 |
Bitewings - two radiographic images |
145 |
136 |
$467.41 |
| D2951 |
|
17 |
12 |
$289.20 |
| D5899 |
|
409 |
271 |
$0.00 |
| D2330 |
|
19 |
12 |
$0.00 |
| D2331 |
|
72 |
51 |
$0.00 |
| D1354 |
|
38 |
13 |
$0.00 |