| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,535 |
913 |
$364K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,142 |
607 |
$207K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
932 |
440 |
$198K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,264 |
1,250 |
$82K |
| D0350 |
|
7,558 |
2,257 |
$56K |
| D9430 |
|
1,621 |
1,323 |
$52K |
| D7140 |
Extraction, erupted tooth or exposed root |
848 |
328 |
$48K |
| D9222 |
|
387 |
385 |
$46K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,809 |
1,880 |
$40K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
519 |
247 |
$34K |
| D2140 |
|
564 |
280 |
$30K |
| D9610 |
|
800 |
418 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
221 |
218 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
246 |
246 |
$11K |
| D0272 |
Bitewings - two radiographic images |
802 |
786 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
137 |
86 |
$9K |
| D2330 |
|
121 |
71 |
$8K |
| D1120 |
Prophylaxis - child |
347 |
346 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
146 |
80 |
$8K |
| D1110 |
Prophylaxis - adult |
88 |
88 |
$7K |
| D1206 |
Topical application of fluoride varnish |
621 |
613 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
440 |
411 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
44 |
26 |
$5K |
| D0274 |
Bitewings - four radiographic images |
230 |
227 |
$4K |
| D1351 |
Sealant - per tooth |
27 |
14 |
$1K |
| D1310 |
|
59 |
59 |
$900.00 |
| D0603 |
|
65 |
65 |
$300.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
13 |
$173.00 |
| D1330 |
|
214 |
214 |
$0.00 |