| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,404 |
651 |
$397K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
439 |
409 |
$122K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,148 |
440 |
$74K |
| D9310 |
|
876 |
846 |
$42K |
| D9222 |
|
430 |
407 |
$33K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
336 |
166 |
$29K |
| D2390 |
|
131 |
49 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
1,225 |
1,181 |
$18K |
| D1120 |
Prophylaxis - child |
490 |
475 |
$12K |
| D0240 |
|
564 |
527 |
$10K |
| D0272 |
Bitewings - two radiographic images |
558 |
532 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,015 |
533 |
$7K |
| D1206 |
Topical application of fluoride varnish |
500 |
485 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
122 |
116 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
47 |
27 |
$3K |
| D9248 |
|
19 |
13 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
166 |
158 |
$2K |
| D2330 |
|
36 |
26 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
52 |
51 |
$1K |
| D1351 |
Sealant - per tooth |
29 |
12 |
$658.53 |