| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,274 |
254 |
$258K |
| D7140 |
Extraction, erupted tooth or exposed root |
457 |
194 |
$45K |
| D0210 |
Intraoral - complete series of radiographic images |
363 |
349 |
$25K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
187 |
88 |
$22K |
| D1120 |
Prophylaxis - child |
586 |
573 |
$19K |
| D9243 |
|
179 |
79 |
$17K |
| D1351 |
Sealant - per tooth |
466 |
154 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
390 |
375 |
$13K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
67 |
27 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
424 |
417 |
$9K |
| D1206 |
Topical application of fluoride varnish |
549 |
536 |
$9K |
| D9239 |
|
88 |
83 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
141 |
135 |
$6K |
| D9222 |
|
31 |
28 |
$5K |
| D0274 |
Bitewings - four radiographic images |
112 |
108 |
$2K |
| D0272 |
Bitewings - two radiographic images |
129 |
125 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
54 |
52 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$390.00 |
| D0220 |
Intraoral - periapical first radiographic image |
24 |
24 |
$182.13 |
| D0230 |
Intraoral - periapical each additional radiographic image |
20 |
20 |
$87.48 |