| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
430 |
146 |
$85K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
277 |
123 |
$27K |
| D1120 |
Prophylaxis - child |
470 |
469 |
$20K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
126 |
83 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
161 |
89 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
336 |
335 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
89 |
56 |
$12K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
109 |
20 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
805 |
278 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
289 |
288 |
$9K |
| D2390 |
|
37 |
14 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
301 |
301 |
$6K |
| D1206 |
Topical application of fluoride varnish |
176 |
176 |
$5K |
| D9248 |
|
75 |
74 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
66 |
66 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
62 |
62 |
$4K |
| D1351 |
Sealant - per tooth |
79 |
31 |
$3K |
| D9222 |
|
20 |
20 |
$2K |
| D0272 |
Bitewings - two radiographic images |
73 |
72 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
25 |
25 |
$1K |