| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,643 |
631 |
$431K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
385 |
384 |
$104K |
| D7140 |
Extraction, erupted tooth or exposed root |
937 |
316 |
$60K |
| D2390 |
|
277 |
81 |
$56K |
| D9310 |
|
781 |
773 |
$37K |
| D9222 |
|
384 |
383 |
$30K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
252 |
124 |
$22K |
| D1120 |
Prophylaxis - child |
441 |
429 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
101 |
53 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
816 |
778 |
$12K |
| D9610 |
|
382 |
381 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
360 |
357 |
$10K |
| D7962 |
|
46 |
46 |
$10K |
| D1206 |
Topical application of fluoride varnish |
525 |
509 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,102 |
558 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
291 |
280 |
$8K |
| D0272 |
Bitewings - two radiographic images |
399 |
397 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
191 |
179 |
$4K |
| D1351 |
Sealant - per tooth |
161 |
58 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
109 |
109 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
45 |
26 |
$3K |
| D2331 |
|
17 |
13 |
$2K |
| D2330 |
|
19 |
13 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$365.88 |