| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,304 |
853 |
$608K |
| D1120 |
Prophylaxis - child |
2,707 |
2,673 |
$84K |
| D7140 |
Extraction, erupted tooth or exposed root |
941 |
469 |
$75K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
131 |
105 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
2,513 |
2,481 |
$61K |
| D0272 |
Bitewings - two radiographic images |
1,517 |
1,493 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,935 |
1,899 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
890 |
871 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
364 |
241 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,085 |
1,083 |
$24K |
| D9222 |
|
104 |
104 |
$24K |
| D2390 |
|
144 |
42 |
$21K |
| D1351 |
Sealant - per tooth |
774 |
236 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
782 |
449 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,323 |
1,301 |
$19K |
| D2933 |
|
115 |
39 |
$18K |
| D9420 |
|
211 |
205 |
$15K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
181 |
90 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
220 |
220 |
$10K |
| D1110 |
Prophylaxis - adult |
215 |
211 |
$9K |
| D2934 |
|
40 |
14 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
235 |
233 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
88 |
57 |
$9K |
| D0330 |
Panoramic radiographic image |
98 |
98 |
$5K |
| D0274 |
Bitewings - four radiographic images |
129 |
129 |
$5K |
| D2330 |
|
66 |
44 |
$5K |
| D1510 |
|
17 |
12 |
$969.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
28 |
28 |
$588.00 |
| D0210 |
Intraoral - complete series of radiographic images |
40 |
12 |
$498.00 |