| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
799 |
519 |
$377K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,221 |
3,220 |
$213K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,800 |
1,321 |
$187K |
| D1120 |
Prophylaxis - child |
3,139 |
3,139 |
$163K |
| D1351 |
Sealant - per tooth |
3,658 |
897 |
$137K |
| D0120 |
Periodic oral evaluation - established patient |
1,145 |
1,145 |
$75K |
| D0230 |
Intraoral - periapical each additional radiographic image |
17,477 |
3,386 |
$72K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
613 |
319 |
$72K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
596 |
236 |
$70K |
| D0210 |
Intraoral - complete series of radiographic images |
1,113 |
1,113 |
$53K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,164 |
3,164 |
$52K |
| D4341 |
|
696 |
191 |
$49K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
609 |
395 |
$48K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
871 |
506 |
$47K |
| D1110 |
Prophylaxis - adult |
435 |
435 |
$39K |
| D1310 |
|
806 |
806 |
$36K |
| D0274 |
Bitewings - four radiographic images |
1,461 |
1,461 |
$31K |
| D0350 |
|
2,397 |
1,076 |
$23K |
| D4910 |
|
301 |
301 |
$23K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
212 |
92 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
272 |
173 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
386 |
361 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,271 |
1,265 |
$15K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
227 |
132 |
$15K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
27 |
25 |
$13K |
| D0603 |
|
768 |
768 |
$11K |
| D4342 |
|
262 |
80 |
$11K |
| D2140 |
|
185 |
98 |
$10K |
| D0145 |
Oral evaluation for a patient under three years of age |
154 |
154 |
$10K |
| D3320 |
|
27 |
26 |
$10K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
69 |
25 |
$10K |
| D9430 |
|
294 |
294 |
$9K |
| D7240 |
Removal of impacted tooth - completely bony |
36 |
12 |
$8K |
| D2335 |
|
62 |
34 |
$7K |
| D1206 |
Topical application of fluoride varnish |
397 |
397 |
$7K |
| D0272 |
Bitewings - two radiographic images |
553 |
553 |
$7K |
| D9222 |
|
25 |
25 |
$3K |
| D2330 |
|
34 |
15 |
$3K |
| D2331 |
|
17 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
44 |
44 |
$1K |