| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,702 |
491 |
$386K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,556 |
358 |
$128K |
| D0145 |
Oral evaluation for a patient under three years of age |
504 |
499 |
$65K |
| D1351 |
Sealant - per tooth |
1,947 |
450 |
$48K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,384 |
1,348 |
$45K |
| D1120 |
Prophylaxis - child |
1,062 |
1,029 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
2,728 |
2,639 |
$31K |
| D0272 |
Bitewings - two radiographic images |
1,479 |
1,423 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,737 |
2,091 |
$27K |
| D9248 |
|
163 |
158 |
$19K |
| D2934 |
|
135 |
42 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,203 |
1,168 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
623 |
572 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
495 |
483 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
114 |
59 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
191 |
190 |
$3K |
| D0160 |
|
118 |
118 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
13 |
$1K |
| D1206 |
Topical application of fluoride varnish |
103 |
102 |
$1K |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$748.05 |
| D0274 |
Bitewings - four radiographic images |
20 |
20 |
$618.78 |
| D2950 |
|
14 |
14 |
$602.00 |
| D0270 |
|
117 |
111 |
$504.70 |
| D0170 |
|
14 |
14 |
$198.48 |
| D0603 |
|
3,168 |
3,117 |
$0.00 |
| D9222 |
|
16 |
15 |
$0.00 |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
34 |
15 |
$0.00 |