| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,738 |
710 |
$497K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,525 |
780 |
$155K |
| D1110 |
Prophylaxis - adult |
2,437 |
2,437 |
$151K |
| D1120 |
Prophylaxis - child |
2,857 |
2,856 |
$134K |
| D0120 |
Periodic oral evaluation - established patient |
4,112 |
4,109 |
$131K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
699 |
464 |
$85K |
| D0274 |
Bitewings - four radiographic images |
1,808 |
1,808 |
$60K |
| D1206 |
Topical application of fluoride varnish |
1,663 |
1,661 |
$58K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
72 |
72 |
$38K |
| D0272 |
Bitewings - two radiographic images |
1,684 |
1,682 |
$34K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
355 |
246 |
$33K |
| D7240 |
Removal of impacted tooth - completely bony |
30 |
30 |
$30K |
| D9310 |
|
271 |
271 |
$29K |
| D0240 |
|
746 |
702 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,676 |
1,676 |
$26K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
177 |
135 |
$23K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
89 |
89 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,035 |
1,024 |
$16K |
| D0330 |
Panoramic radiographic image |
225 |
225 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
318 |
318 |
$9K |
| D9222 |
|
88 |
88 |
$8K |
| D1510 |
|
31 |
27 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
129 |
129 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
49 |
49 |
$518.00 |