| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,667 |
345 |
$180K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,677 |
489 |
$130K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
80 |
77 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
465 |
249 |
$27K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
284 |
125 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
390 |
229 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
500 |
497 |
$18K |
| D1110 |
Prophylaxis - adult |
491 |
487 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
817 |
646 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
751 |
746 |
$15K |
| D1206 |
Topical application of fluoride varnish |
902 |
900 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
725 |
722 |
$14K |
| D1120 |
Prophylaxis - child |
388 |
388 |
$12K |
| D9222 |
|
81 |
78 |
$11K |
| D0272 |
Bitewings - two radiographic images |
477 |
474 |
$7K |
| D9920 |
|
54 |
54 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
148 |
136 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
97 |
67 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
785 |
780 |
$6K |
| D0330 |
Panoramic radiographic image |
119 |
116 |
$4K |
| D1351 |
Sealant - per tooth |
115 |
32 |
$3K |
| D2330 |
|
53 |
38 |
$3K |
| D1310 |
|
264 |
264 |
$3K |
| D1330 |
|
235 |
235 |
$3K |
| D8670 |
Periodic orthodontic treatment visit |
24 |
24 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
42 |
41 |
$729.36 |