| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
481 |
92 |
$97K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
717 |
114 |
$81K |
| D7140 |
Extraction, erupted tooth or exposed root |
310 |
101 |
$26K |
| D0140 |
Limited oral evaluation - problem focused |
482 |
467 |
$24K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
87 |
42 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
98 |
57 |
$11K |
| D9420 |
|
78 |
77 |
$10K |
| D9222 |
|
101 |
101 |
$10K |
| D2330 |
|
73 |
34 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
353 |
107 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
105 |
104 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
43 |
15 |
$4K |
| D1120 |
Prophylaxis - child |
96 |
95 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
112 |
108 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
128 |
127 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
58 |
57 |
$2K |
| D0272 |
Bitewings - two radiographic images |
48 |
48 |
$1K |