| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
6,148 |
1,815 |
$631K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,631 |
2,400 |
$376K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
2,640 |
408 |
$284K |
| D1120 |
Prophylaxis - child |
6,109 |
5,905 |
$187K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,119 |
1,620 |
$185K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,019 |
3,535 |
$177K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,171 |
913 |
$168K |
| D0230 |
Intraoral - periapical each additional radiographic image |
18,105 |
4,575 |
$163K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,650 |
1,302 |
$149K |
| D9310 |
|
3,117 |
3,004 |
$148K |
| D0120 |
Periodic oral evaluation - established patient |
2,739 |
2,714 |
$112K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,023 |
1,975 |
$96K |
| D2934 |
|
893 |
202 |
$91K |
| D1351 |
Sealant - per tooth |
3,343 |
1,085 |
$74K |
| D0220 |
Intraoral - periapical first radiographic image |
4,369 |
4,079 |
$53K |
| D1206 |
Topical application of fluoride varnish |
3,475 |
3,313 |
$51K |
| D0145 |
Oral evaluation for a patient under three years of age |
602 |
597 |
$30K |
| D9222 |
|
244 |
190 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,037 |
1,992 |
$24K |
| D2330 |
|
278 |
168 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
483 |
470 |
$19K |
| D2332 |
|
169 |
111 |
$15K |
| D0272 |
Bitewings - two radiographic images |
1,275 |
1,263 |
$15K |
| D1510 |
|
76 |
49 |
$9K |
| D1310 |
|
191 |
191 |
$9K |
| D9221 |
|
326 |
68 |
$6K |
| D9430 |
|
102 |
102 |
$3K |
| D9993 |
|
46 |
46 |
$3K |
| D9220 |
|
87 |
68 |
$3K |
| D1999 |
|
414 |
294 |
$2K |
| D0603 |
|
256 |
254 |
$2K |
| D0330 |
Panoramic radiographic image |
44 |
41 |
$1K |
| D0274 |
Bitewings - four radiographic images |
41 |
39 |
$756.00 |
| D0350 |
|
574 |
244 |
$691.20 |
| D0602 |
|
12 |
12 |
$165.00 |
| D1330 |
|
183 |
182 |
$0.00 |