| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,354 |
325 |
$243K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
235 |
174 |
$135K |
| D1120 |
Prophylaxis - child |
1,483 |
1,480 |
$53K |
| D7140 |
Extraction, erupted tooth or exposed root |
682 |
291 |
$50K |
| D9222 |
|
173 |
173 |
$40K |
| D1206 |
Topical application of fluoride varnish |
1,470 |
1,465 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,003 |
998 |
$32K |
| D2933 |
|
136 |
51 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,011 |
604 |
$24K |
| D0272 |
Bitewings - two radiographic images |
596 |
596 |
$17K |
| D1351 |
Sealant - per tooth |
597 |
201 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
360 |
360 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
131 |
98 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
782 |
778 |
$13K |
| D2934 |
|
54 |
18 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
243 |
243 |
$11K |
| D0330 |
Panoramic radiographic image |
175 |
174 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
274 |
258 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
104 |
72 |
$10K |
| D0274 |
Bitewings - four radiographic images |
231 |
228 |
$8K |
| D1510 |
|
36 |
25 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
208 |
208 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
21 |
13 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
85 |
35 |
$1K |