| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,111 |
353 |
$425K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
2,110 |
323 |
$216K |
| D9222 |
|
323 |
323 |
$33K |
| D7140 |
Extraction, erupted tooth or exposed root |
345 |
140 |
$30K |
| D2934 |
|
95 |
30 |
$22K |
| D1120 |
Prophylaxis - child |
201 |
201 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
53 |
28 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
498 |
181 |
$7K |
| D1206 |
Topical application of fluoride varnish |
175 |
175 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
40 |
26 |
$5K |
| D1510 |
|
19 |
14 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
197 |
197 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
108 |
108 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
52 |
52 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
16 |
$2K |
| D0240 |
|
76 |
38 |
$2K |
| D0272 |
Bitewings - two radiographic images |
46 |
46 |
$1K |
| D1351 |
Sealant - per tooth |
34 |
15 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$559.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$289.21 |