| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
880 |
830 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
1,189 |
1,133 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,571 |
1,474 |
$23K |
| D7240 |
Removal of impacted tooth - completely bony |
68 |
18 |
$15K |
| D1110 |
Prophylaxis - adult |
383 |
360 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,189 |
396 |
$11K |
| D1351 |
Sealant - per tooth |
326 |
112 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
191 |
171 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
486 |
457 |
$5K |
| D0272 |
Bitewings - two radiographic images |
265 |
248 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
52 |
37 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
144 |
133 |
$4K |
| D9222 |
|
19 |
19 |
$3K |
| D0274 |
Bitewings - four radiographic images |
116 |
102 |
$3K |
| D0330 |
Panoramic radiographic image |
65 |
63 |
$2K |
| D1354 |
|
52 |
28 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
56 |
55 |
$2K |
| D1999 |
|
69 |
63 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
14 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
15 |
$1K |
| D0240 |
|
35 |
22 |
$472.50 |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
19 |
19 |
$0.00 |