| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,528 |
560 |
$505K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
2,004 |
363 |
$208K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
627 |
274 |
$81K |
| D7140 |
Extraction, erupted tooth or exposed root |
660 |
301 |
$57K |
| D2934 |
|
179 |
63 |
$42K |
| D9222 |
|
363 |
363 |
$38K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,160 |
680 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
216 |
132 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
287 |
164 |
$28K |
| D1120 |
Prophylaxis - child |
689 |
689 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
576 |
576 |
$17K |
| D2330 |
|
175 |
82 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
433 |
433 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
757 |
753 |
$14K |
| D1510 |
|
44 |
33 |
$9K |
| D1351 |
Sealant - per tooth |
250 |
88 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
88 |
87 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
87 |
87 |
$5K |
| D9310 |
|
52 |
52 |
$4K |
| D9248 |
|
64 |
63 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
53 |
53 |
$2K |
| D1206 |
Topical application of fluoride varnish |
81 |
81 |
$2K |
| D0272 |
Bitewings - two radiographic images |
69 |
69 |
$2K |