| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,740 |
1,817 |
$602K |
| D1120 |
Prophylaxis - child |
16,702 |
16,683 |
$557K |
| D0120 |
Periodic oral evaluation - established patient |
18,604 |
18,584 |
$444K |
| D7140 |
Extraction, erupted tooth or exposed root |
4,135 |
2,350 |
$410K |
| D1110 |
Prophylaxis - adult |
7,356 |
7,340 |
$336K |
| D0220 |
Intraoral - periapical first radiographic image |
18,435 |
18,212 |
$234K |
| D1206 |
Topical application of fluoride varnish |
12,219 |
12,181 |
$234K |
| D0210 |
Intraoral - complete series of radiographic images |
2,920 |
2,904 |
$227K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,015 |
1,357 |
$220K |
| D0272 |
Bitewings - two radiographic images |
10,245 |
10,238 |
$215K |
| D0230 |
Intraoral - periapical each additional radiographic image |
16,280 |
16,209 |
$207K |
| D1351 |
Sealant - per tooth |
5,738 |
1,569 |
$205K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
5,928 |
5,625 |
$184K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,533 |
961 |
$158K |
| D0274 |
Bitewings - four radiographic images |
4,320 |
4,310 |
$130K |
| D2140 |
|
1,531 |
1,074 |
$129K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
960 |
653 |
$126K |
| D1208 |
Topical application of fluoride, excluding varnish |
9,037 |
9,018 |
$114K |
| D7240 |
Removal of impacted tooth - completely bony |
268 |
83 |
$72K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,740 |
1,740 |
$69K |
| D2160 |
|
495 |
345 |
$67K |
| D0140 |
Limited oral evaluation - problem focused |
1,467 |
1,452 |
$51K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,029 |
1,028 |
$33K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
306 |
111 |
$26K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
163 |
125 |
$26K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
174 |
173 |
$26K |
| D9222 |
|
172 |
171 |
$17K |
| D0330 |
Panoramic radiographic image |
234 |
234 |
$12K |
| D0350 |
|
254 |
208 |
$11K |
| D9243 |
|
44 |
44 |
$8K |
| D2330 |
|
50 |
28 |
$5K |
| D9239 |
|
44 |
44 |
$5K |
| D9310 |
|
58 |
58 |
$2K |
| D9219 |
|
26 |
26 |
$1K |
| D0190 |
|
21 |
21 |
$338.73 |