| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
523 |
69 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
2,272 |
2,248 |
$64K |
| D1120 |
Prophylaxis - child |
1,414 |
1,400 |
$51K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,257 |
2,514 |
$47K |
| D1110 |
Prophylaxis - adult |
851 |
843 |
$45K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,449 |
2,424 |
$35K |
| D1351 |
Sealant - per tooth |
1,287 |
247 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
345 |
176 |
$33K |
| D0274 |
Bitewings - four radiographic images |
1,002 |
992 |
$33K |
| D0220 |
Intraoral - periapical first radiographic image |
2,694 |
2,658 |
$32K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
227 |
48 |
$18K |
| D0272 |
Bitewings - two radiographic images |
554 |
547 |
$13K |
| D7240 |
Removal of impacted tooth - completely bony |
40 |
13 |
$10K |
| D0145 |
Oral evaluation for a patient under three years of age |
63 |
63 |
$9K |
| D0350 |
|
657 |
644 |
$8K |
| D2934 |
|
53 |
13 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
85 |
83 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
137 |
136 |
$3K |
| D9239 |
|
13 |
13 |
$741.52 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
21 |
20 |
$567.23 |
| D9243 |
|
14 |
13 |
$556.14 |
| D0160 |
|
36 |
36 |
$506.81 |
| D9612 |
|
13 |
13 |
$465.79 |
| D0330 |
Panoramic radiographic image |
47 |
45 |
$346.09 |
| D0603 |
|
2,804 |
2,776 |
$0.00 |
| D0602 |
|
34 |
34 |
$0.00 |
| D9222 |
|
21 |
21 |
$0.00 |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
44 |
22 |
$0.00 |