| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
2,354 |
892 |
$550K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,484 |
889 |
$421K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,256 |
966 |
$164K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,241 |
659 |
$128K |
| D2740 |
Crown - porcelain/ceramic |
256 |
193 |
$122K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,335 |
561 |
$113K |
| D9222 |
|
931 |
890 |
$106K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,599 |
2,585 |
$83K |
| D1110 |
Prophylaxis - adult |
478 |
478 |
$43K |
| D0220 |
Intraoral - periapical first radiographic image |
3,082 |
2,957 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
826 |
782 |
$30K |
| D4910 |
|
165 |
165 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
399 |
399 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
358 |
200 |
$17K |
| D1510 |
|
114 |
74 |
$15K |
| D1206 |
Topical application of fluoride varnish |
908 |
898 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
296 |
296 |
$14K |
| D9310 |
|
342 |
337 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
141 |
107 |
$13K |
| D0274 |
Bitewings - four radiographic images |
491 |
491 |
$11K |
| D1999 |
|
2,530 |
2,343 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
206 |
185 |
$8K |
| D2330 |
|
105 |
58 |
$7K |
| D9221 |
|
21 |
13 |
$7K |
| D9430 |
|
238 |
226 |
$7K |
| D0350 |
|
1,451 |
613 |
$6K |
| D1320 |
|
707 |
707 |
$5K |
| D2332 |
|
72 |
41 |
$5K |
| D1120 |
Prophylaxis - child |
129 |
122 |
$4K |
| D9220 |
|
13 |
13 |
$3K |
| D0272 |
Bitewings - two radiographic images |
124 |
121 |
$2K |
| D1310 |
|
276 |
208 |
$1K |
| D9993 |
|
207 |
181 |
$958.75 |
| D1351 |
Sealant - per tooth |
17 |
12 |
$749.00 |
| D0270 |
|
92 |
92 |
$460.00 |
| D0603 |
|
227 |
198 |
$296.25 |
| D0431 |
|
36 |
36 |
$0.00 |