| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
15,090 |
2,682 |
$1.78M |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
6,965 |
3,673 |
$708K |
| D1120 |
Prophylaxis - child |
19,289 |
18,994 |
$578K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
1,648 |
1,647 |
$476K |
| D0120 |
Periodic oral evaluation - established patient |
19,894 |
19,531 |
$417K |
| D1208 |
Topical application of fluoride, excluding varnish |
19,275 |
19,050 |
$287K |
| D1110 |
Prophylaxis - adult |
6,152 |
6,036 |
$275K |
| D7140 |
Extraction, erupted tooth or exposed root |
4,102 |
2,056 |
$267K |
| D0220 |
Intraoral - periapical first radiographic image |
15,953 |
15,649 |
$238K |
| D0330 |
Panoramic radiographic image |
4,918 |
4,867 |
$235K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,700 |
2,129 |
$220K |
| D1351 |
Sealant - per tooth |
8,300 |
2,319 |
$202K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,209 |
817 |
$174K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,949 |
851 |
$172K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
6,265 |
5,955 |
$169K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,016 |
4,956 |
$150K |
| D0272 |
Bitewings - two radiographic images |
8,271 |
8,166 |
$149K |
| D0140 |
Limited oral evaluation - problem focused |
4,696 |
4,630 |
$139K |
| D0230 |
Intraoral - periapical each additional radiographic image |
14,364 |
11,766 |
$108K |
| D9222 |
|
1,338 |
1,337 |
$105K |
| D1206 |
Topical application of fluoride varnish |
5,833 |
5,628 |
$100K |
| D0274 |
Bitewings - four radiographic images |
2,563 |
2,519 |
$77K |
| D2390 |
|
169 |
52 |
$35K |
| D0145 |
Oral evaluation for a patient under three years of age |
664 |
656 |
$20K |
| D9610 |
|
565 |
565 |
$17K |
| D7240 |
Removal of impacted tooth - completely bony |
46 |
14 |
$10K |
| D2330 |
|
144 |
107 |
$9K |
| D1510 |
|
20 |
14 |
$2K |
| D3120 |
|
74 |
51 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
13 |
12 |
$2K |
| D1354 |
|
42 |
13 |
$1K |
| D0601 |
|
12 |
12 |
$109.80 |