| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,650 |
4,624 |
$285K |
| D0120 |
Periodic oral evaluation - established patient |
3,593 |
3,588 |
$181K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,730 |
1,503 |
$177K |
| D0210 |
Intraoral - complete series of radiographic images |
2,663 |
2,639 |
$121K |
| D1120 |
Prophylaxis - child |
3,422 |
3,385 |
$118K |
| D2740 |
Crown - porcelain/ceramic |
238 |
186 |
$109K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
863 |
316 |
$101K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
212 |
165 |
$99K |
| D0230 |
Intraoral - periapical each additional radiographic image |
23,405 |
6,566 |
$94K |
| D0274 |
Bitewings - four radiographic images |
4,642 |
4,574 |
$94K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,678 |
944 |
$89K |
| D9430 |
|
2,687 |
2,629 |
$85K |
| D1110 |
Prophylaxis - adult |
748 |
738 |
$62K |
| D1351 |
Sealant - per tooth |
2,980 |
607 |
$61K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
130 |
85 |
$24K |
| D4341 |
|
392 |
112 |
$24K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
54 |
49 |
$23K |
| D4910 |
|
232 |
230 |
$18K |
| D3320 |
|
45 |
37 |
$16K |
| D0330 |
Panoramic radiographic image |
353 |
353 |
$10K |
| D9222 |
|
85 |
85 |
$10K |
| D0350 |
|
1,474 |
527 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
752 |
747 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
89 |
67 |
$7K |
| D1206 |
Topical application of fluoride varnish |
612 |
593 |
$6K |
| D7230 |
|
31 |
12 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
473 |
473 |
$5K |
| D2954 |
|
42 |
38 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
70 |
41 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
102 |
100 |
$4K |
| D9610 |
|
90 |
57 |
$3K |
| D0272 |
Bitewings - two radiographic images |
256 |
254 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
24 |
15 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
24 |
15 |
$2K |
| D4342 |
|
37 |
12 |
$2K |
| D0270 |
|
267 |
256 |
$1K |
| D9241 |
|
17 |
16 |
$885.00 |
| D9242 |
|
15 |
14 |
$442.50 |
| D9910 |
|
39 |
13 |
$0.00 |