| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
4,900 |
2,746 |
$2.13M |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
14,220 |
2,911 |
$1.66M |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
14,834 |
2,989 |
$1.44M |
| D9222 |
|
2,750 |
2,737 |
$335K |
| D2330 |
|
3,843 |
1,532 |
$292K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
4,039 |
1,431 |
$263K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
4,641 |
1,904 |
$250K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,863 |
1,436 |
$214K |
| D9610 |
|
2,882 |
2,361 |
$194K |
| D9221 |
|
687 |
350 |
$185K |
| D7240 |
Removal of impacted tooth - completely bony |
723 |
301 |
$166K |
| D1510 |
|
710 |
503 |
$133K |
| D2140 |
|
2,081 |
825 |
$112K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,200 |
481 |
$77K |
| D9220 |
|
323 |
322 |
$76K |
| D2331 |
|
943 |
473 |
$72K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12,956 |
4,633 |
$56K |
| D1120 |
Prophylaxis - child |
1,789 |
1,784 |
$52K |
| D0120 |
Periodic oral evaluation - established patient |
1,152 |
1,146 |
$48K |
| D0272 |
Bitewings - two radiographic images |
2,982 |
2,973 |
$34K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
838 |
825 |
$33K |
| D1351 |
Sealant - per tooth |
1,102 |
335 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
442 |
441 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,782 |
1,776 |
$20K |
| D0350 |
|
2,419 |
895 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,244 |
1,235 |
$14K |
| D9993 |
|
177 |
177 |
$11K |
| D7230 |
|
58 |
32 |
$11K |
| D1310 |
|
202 |
202 |
$9K |
| D8670 |
Periodic orthodontic treatment visit |
26 |
26 |
$8K |
| D9430 |
|
208 |
206 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
155 |
155 |
$5K |
| D0330 |
Panoramic radiographic image |
146 |
146 |
$4K |
| D0603 |
|
109 |
109 |
$2K |
| D0274 |
Bitewings - four radiographic images |
68 |
68 |
$1K |
| D0601 |
|
13 |
13 |
$180.00 |