| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,721 |
1,392 |
$469K |
| D7140 |
Extraction, erupted tooth or exposed root |
7,426 |
2,925 |
$360K |
| D1120 |
Prophylaxis - child |
11,358 |
10,264 |
$304K |
| D8670 |
Periodic orthodontic treatment visit |
2,265 |
1,026 |
$206K |
| D0120 |
Periodic oral evaluation - established patient |
11,032 |
9,920 |
$187K |
| D1206 |
Topical application of fluoride varnish |
10,889 |
9,661 |
$170K |
| D1351 |
Sealant - per tooth |
7,927 |
2,287 |
$156K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,274 |
1,431 |
$119K |
| D0272 |
Bitewings - two radiographic images |
8,697 |
7,814 |
$116K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,559 |
4,080 |
$110K |
| D0330 |
Panoramic radiographic image |
4,054 |
3,620 |
$109K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,581 |
1,064 |
$104K |
| D1110 |
Prophylaxis - adult |
2,738 |
2,407 |
$100K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
728 |
246 |
$93K |
| D0140 |
Limited oral evaluation - problem focused |
3,354 |
2,913 |
$65K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,187 |
1,975 |
$57K |
| D9248 |
|
737 |
679 |
$54K |
| D0220 |
Intraoral - periapical first radiographic image |
5,157 |
4,200 |
$50K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
239 |
149 |
$46K |
| D8660 |
|
885 |
856 |
$39K |
| D0274 |
Bitewings - four radiographic images |
1,728 |
1,495 |
$38K |
| D0210 |
Intraoral - complete series of radiographic images |
943 |
815 |
$36K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
936 |
316 |
$24K |
| D8080 |
Comprehensive orthodontic treatment of the adolescent dentition |
18 |
18 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,491 |
1,455 |
$21K |
| D9222 |
|
324 |
316 |
$17K |
| D1354 |
|
3,953 |
957 |
$16K |
| D1353 |
|
1,064 |
350 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,074 |
654 |
$7K |
| D2950 |
|
278 |
158 |
$3K |
| D1510 |
|
16 |
12 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
30 |
24 |
$2K |
| D4342 |
|
44 |
25 |
$1K |
| D2331 |
|
19 |
13 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
13 |
13 |
$1K |
| D2330 |
|
18 |
14 |
$951.60 |
| D1352 |
|
47 |
27 |
$420.00 |
| D1330 |
|
58 |
55 |
$0.00 |
| D0240 |
|
83 |
64 |
$0.00 |