| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
1,143 |
326 |
$165K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,321 |
289 |
$157K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
793 |
238 |
$79K |
| D9222 |
|
323 |
322 |
$39K |
| D7140 |
Extraction, erupted tooth or exposed root |
633 |
225 |
$35K |
| D9610 |
|
938 |
324 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
263 |
263 |
$17K |
| D0350 |
|
1,157 |
298 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,197 |
332 |
$8K |
| D1510 |
|
39 |
27 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
109 |
56 |
$6K |
| D0272 |
Bitewings - two radiographic images |
323 |
322 |
$4K |
| D1351 |
Sealant - per tooth |
100 |
32 |
$4K |
| D2330 |
|
37 |
25 |
$3K |
| D2140 |
|
31 |
16 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
18 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$525.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$219.50 |