| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
302 |
42 |
$36K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
266 |
63 |
$33K |
| D9222 |
|
63 |
62 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
85 |
85 |
$6K |
| D9610 |
|
236 |
63 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
59 |
14 |
$3K |
| D1120 |
Prophylaxis - child |
41 |
41 |
$2K |
| D0350 |
|
204 |
55 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
404 |
88 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
28 |
28 |
$675.50 |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$480.00 |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$300.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$144.00 |
| D0274 |
Bitewings - four radiographic images |
36 |
36 |
$21.60 |
| D0120 |
Periodic oral evaluation - established patient |
29 |
29 |
$0.00 |