| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
1,613 |
730 |
$135K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
202 |
201 |
$70K |
| D9222 |
|
202 |
201 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
594 |
385 |
$38K |
| D5110 |
|
66 |
66 |
$36K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
283 |
120 |
$30K |
| D1110 |
Prophylaxis - adult |
589 |
586 |
$21K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
291 |
216 |
$20K |
| D5120 |
|
29 |
29 |
$15K |
| D1120 |
Prophylaxis - child |
459 |
459 |
$15K |
| D0330 |
Panoramic radiographic image |
455 |
453 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
271 |
203 |
$14K |
| D1206 |
Topical application of fluoride varnish |
767 |
764 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
701 |
699 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
853 |
842 |
$13K |
| D0274 |
Bitewings - four radiographic images |
498 |
496 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
257 |
254 |
$12K |
| D1330 |
|
1,006 |
1,004 |
$12K |
| D1310 |
|
1,017 |
1,015 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
560 |
559 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
187 |
187 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,091 |
1,082 |
$8K |
| D1351 |
Sealant - per tooth |
214 |
34 |
$6K |
| D2332 |
|
75 |
51 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
77 |
77 |
$4K |
| D0272 |
Bitewings - two radiographic images |
254 |
254 |
$4K |
| D2335 |
|
25 |
12 |
$2K |