| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,743 |
481 |
$328K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,623 |
366 |
$160K |
| D1120 |
Prophylaxis - child |
2,496 |
2,474 |
$126K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,481 |
1,473 |
$99K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
189 |
101 |
$76K |
| D0120 |
Periodic oral evaluation - established patient |
1,112 |
1,097 |
$75K |
| D1310 |
|
1,540 |
1,523 |
$68K |
| D1206 |
Topical application of fluoride varnish |
1,861 |
1,839 |
$47K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,761 |
1,919 |
$41K |
| D0145 |
Oral evaluation for a patient under three years of age |
476 |
474 |
$33K |
| D7140 |
Extraction, erupted tooth or exposed root |
565 |
238 |
$32K |
| D1351 |
Sealant - per tooth |
713 |
223 |
$27K |
| D9430 |
|
804 |
785 |
$26K |
| D0603 |
|
1,307 |
1,289 |
$19K |
| D0272 |
Bitewings - two radiographic images |
1,405 |
1,395 |
$16K |
| D9222 |
|
101 |
101 |
$12K |
| D9248 |
|
292 |
290 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
576 |
575 |
$8K |
| D9610 |
|
101 |
101 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
109 |
59 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
125 |
65 |
$7K |
| D9920 |
|
47 |
46 |
$6K |
| D0350 |
|
677 |
280 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
117 |
117 |
$5K |
| D0602 |
|
178 |
178 |
$3K |
| D7111 |
|
40 |
14 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
144 |
140 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
22 |
20 |
$880.00 |
| D0274 |
Bitewings - four radiographic images |
40 |
40 |
$864.00 |