| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,027 |
303 |
$101K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
791 |
272 |
$94K |
| D1120 |
Prophylaxis - child |
1,685 |
1,683 |
$84K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,046 |
1,046 |
$70K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
278 |
52 |
$58K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
710 |
369 |
$47K |
| D1310 |
|
953 |
952 |
$41K |
| D1206 |
Topical application of fluoride varnish |
1,670 |
1,668 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
424 |
424 |
$30K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
735 |
643 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,263 |
1,629 |
$26K |
| D0145 |
Oral evaluation for a patient under three years of age |
296 |
296 |
$19K |
| D1351 |
Sealant - per tooth |
478 |
162 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
321 |
183 |
$18K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
228 |
145 |
$18K |
| D0272 |
Bitewings - two radiographic images |
1,331 |
1,327 |
$16K |
| D9222 |
|
52 |
52 |
$6K |
| D0601 |
|
346 |
345 |
$5K |
| D0603 |
|
299 |
299 |
$4K |
| D9610 |
|
138 |
51 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
37 |
14 |
$2K |
| D2332 |
|
26 |
13 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
25 |
$2K |
| D0602 |
|
107 |
107 |
$2K |