| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,432 |
307 |
$168K |
| D1120 |
Prophylaxis - child |
2,210 |
2,208 |
$110K |
| D1351 |
Sealant - per tooth |
2,515 |
584 |
$94K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,168 |
1,166 |
$77K |
| D1310 |
|
1,341 |
1,340 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
861 |
861 |
$56K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
191 |
76 |
$50K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
456 |
152 |
$45K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,946 |
1,944 |
$39K |
| D7140 |
Extraction, erupted tooth or exposed root |
579 |
280 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,978 |
1,915 |
$33K |
| D2330 |
|
340 |
111 |
$27K |
| D0145 |
Oral evaluation for a patient under three years of age |
340 |
339 |
$22K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
573 |
535 |
$22K |
| D0603 |
|
1,300 |
1,296 |
$19K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
221 |
107 |
$15K |
| D2140 |
|
264 |
102 |
$14K |
| D9430 |
|
296 |
284 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
798 |
770 |
$9K |
| D9222 |
|
78 |
76 |
$9K |
| D0272 |
Bitewings - two radiographic images |
844 |
841 |
$9K |
| D1206 |
Topical application of fluoride varnish |
293 |
293 |
$9K |
| D0350 |
|
1,159 |
389 |
$9K |
| D0274 |
Bitewings - four radiographic images |
369 |
369 |
$7K |
| D0340 |
|
142 |
142 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
197 |
197 |
$7K |
| D0330 |
Panoramic radiographic image |
212 |
211 |
$6K |
| D9610 |
|
174 |
61 |
$5K |
| D2335 |
|
32 |
14 |
$4K |
| D1320 |
|
85 |
85 |
$865.00 |
| D9920 |
|
30 |
30 |
$700.00 |