| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
858 |
813 |
$576K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
3,125 |
1,260 |
$450K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
4,652 |
710 |
$293K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,423 |
584 |
$279K |
| D0140 |
Limited oral evaluation - problem focused |
6,197 |
5,929 |
$277K |
| D7230 |
|
880 |
522 |
$184K |
| D7240 |
Removal of impacted tooth - completely bony |
622 |
289 |
$157K |
| D3320 |
|
283 |
249 |
$152K |
| D7250 |
|
684 |
292 |
$98K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,099 |
524 |
$97K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
741 |
395 |
$95K |
| D0220 |
Intraoral - periapical first radiographic image |
5,500 |
5,021 |
$92K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,235 |
4,159 |
$79K |
| D9222 |
|
745 |
707 |
$76K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
619 |
392 |
$55K |
| D1120 |
Prophylaxis - child |
1,036 |
1,031 |
$45K |
| D3348 |
|
52 |
51 |
$43K |
| D0330 |
Panoramic radiographic image |
1,210 |
1,192 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
581 |
579 |
$28K |
| D1206 |
Topical application of fluoride varnish |
929 |
928 |
$26K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
188 |
141 |
$24K |
| D0240 |
|
1,021 |
515 |
$20K |
| D1510 |
|
84 |
70 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
450 |
449 |
$15K |
| D4341 |
|
116 |
41 |
$13K |
| D1351 |
Sealant - per tooth |
372 |
143 |
$11K |
| D3310 |
|
18 |
12 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
98 |
96 |
$6K |
| D2330 |
|
56 |
36 |
$5K |
| D7220 |
|
35 |
26 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
65 |
65 |
$3K |
| D9310 |
|
29 |
29 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
52 |
52 |
$892.50 |
| D0272 |
Bitewings - two radiographic images |
50 |
48 |
$719.46 |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$353.45 |
| D3120 |
|
118 |
66 |
$0.00 |