| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,170 |
509 |
$377K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,759 |
397 |
$173K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
520 |
365 |
$139K |
| D9222 |
|
365 |
365 |
$44K |
| D9420 |
|
554 |
553 |
$38K |
| D7140 |
Extraction, erupted tooth or exposed root |
576 |
223 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
497 |
497 |
$31K |
| D0350 |
|
1,039 |
532 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,578 |
552 |
$13K |
| D1510 |
|
73 |
52 |
$9K |
| D0272 |
Bitewings - two radiographic images |
549 |
548 |
$6K |
| D2332 |
|
37 |
16 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
17 |
$1K |
| D2140 |
|
24 |
14 |
$1K |
| D1351 |
Sealant - per tooth |
33 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
16 |
16 |
$330.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
17 |
17 |
$176.00 |
| D1999 |
|
14 |
14 |
$0.00 |