| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,467 |
298 |
$295K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
1,792 |
270 |
$179K |
| D7140 |
Extraction, erupted tooth or exposed root |
569 |
168 |
$50K |
| D9222 |
|
258 |
257 |
$26K |
| D2934 |
|
100 |
37 |
$23K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
135 |
71 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
541 |
176 |
$7K |
| D2330 |
|
49 |
28 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
217 |
214 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
60 |
60 |
$4K |
| D1120 |
Prophylaxis - child |
82 |
82 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
14 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
39 |
39 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
76 |
76 |
$2K |