| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,268 |
231 |
$255K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
1,387 |
221 |
$142K |
| D7140 |
Extraction, erupted tooth or exposed root |
327 |
112 |
$28K |
| D9222 |
|
222 |
221 |
$23K |
| D2934 |
|
62 |
25 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
394 |
131 |
$5K |
| D1510 |
|
22 |
13 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
150 |
150 |
$3K |
| D2330 |
|
30 |
14 |
$3K |
| D1120 |
Prophylaxis - child |
29 |
29 |
$523.68 |
| D1206 |
Topical application of fluoride varnish |
27 |
27 |
$237.10 |
| D0120 |
Periodic oral evaluation - established patient |
13 |
13 |
$152.96 |