| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,472 |
1,166 |
$672K |
| D9420 |
|
2,105 |
2,049 |
$169K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,755 |
561 |
$153K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,576 |
558 |
$97K |
| D0210 |
Intraoral - complete series of radiographic images |
1,672 |
1,637 |
$96K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,797 |
2,743 |
$89K |
| D1351 |
Sealant - per tooth |
2,935 |
327 |
$80K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
718 |
273 |
$58K |
| D2934 |
|
380 |
138 |
$51K |
| D2330 |
|
690 |
241 |
$50K |
| D0140 |
Limited oral evaluation - problem focused |
1,281 |
1,247 |
$38K |
| D1120 |
Prophylaxis - child |
906 |
906 |
$31K |
| D7240 |
Removal of impacted tooth - completely bony |
198 |
70 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,955 |
782 |
$22K |
| D1206 |
Topical application of fluoride varnish |
1,102 |
1,101 |
$21K |
| D0330 |
Panoramic radiographic image |
442 |
434 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
560 |
560 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
835 |
831 |
$11K |
| D0274 |
Bitewings - four radiographic images |
345 |
344 |
$11K |
| D1110 |
Prophylaxis - adult |
155 |
155 |
$7K |
| D0272 |
Bitewings - two radiographic images |
245 |
245 |
$6K |
| D9310 |
|
176 |
171 |
$5K |
| D7230 |
|
25 |
14 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
100 |
95 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
13 |
$3K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
35 |
17 |
$2K |
| D9222 |
|
18 |
17 |
$2K |
| D0240 |
|
28 |
14 |
$534.24 |
| D9610 |
|
18 |
17 |
$357.00 |
| D9219 |
|
18 |
16 |
$352.80 |
| D1999 |
|
306 |
292 |
$18.75 |
| D0603 |
|
4,399 |
4,025 |
$0.00 |
| D1330 |
|
1,135 |
1,101 |
$0.00 |