| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
502 |
99 |
$57K |
| D9221 |
|
261 |
140 |
$50K |
| D1120 |
Prophylaxis - child |
1,383 |
1,352 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
766 |
752 |
$30K |
| D9220 |
|
148 |
141 |
$29K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
158 |
48 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,372 |
1,341 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
934 |
880 |
$14K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
37 |
17 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
263 |
259 |
$11K |
| D9610 |
|
235 |
156 |
$10K |
| D9430 |
|
321 |
311 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
145 |
49 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
467 |
462 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
131 |
128 |
$5K |
| D0272 |
Bitewings - two radiographic images |
278 |
276 |
$3K |
| D9222 |
|
17 |
17 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
44 |
43 |
$2K |
| D0350 |
|
87 |
71 |
$2K |