| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
301 |
122 |
$52K |
| D9310 |
|
683 |
683 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
219 |
116 |
$25K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
26 |
26 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,099 |
568 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
215 |
211 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
600 |
593 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
82 |
42 |
$7K |
| D0272 |
Bitewings - two radiographic images |
264 |
264 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
33 |
13 |
$4K |
| D9222 |
|
14 |
14 |
$2K |
| D1310 |
|
39 |
39 |
$2K |
| D0603 |
|
52 |
52 |
$585.00 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$330.40 |