| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
2,990 |
2,980 |
$106K |
| D1120 |
Prophylaxis - child |
2,062 |
2,057 |
$95K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,506 |
1,499 |
$87K |
| D0120 |
Periodic oral evaluation - established patient |
1,691 |
1,690 |
$76K |
| D1310 |
|
1,104 |
1,104 |
$43K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
225 |
40 |
$36K |
| D9999 |
Unspecified adjunctive procedure, by report |
317 |
235 |
$36K |
| D1110 |
Prophylaxis - adult |
467 |
467 |
$34K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
162 |
71 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
2,205 |
2,190 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,838 |
2,004 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
330 |
233 |
$20K |
| D1351 |
Sealant - per tooth |
538 |
155 |
$19K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
408 |
358 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
182 |
104 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
218 |
167 |
$10K |
| D0330 |
Panoramic radiographic image |
445 |
445 |
$9K |
| D0272 |
Bitewings - two radiographic images |
832 |
832 |
$8K |
| D9610 |
|
136 |
40 |
$7K |
| D9310 |
|
141 |
141 |
$7K |
| D9430 |
|
257 |
252 |
$7K |
| D0601 |
|
1,005 |
1,002 |
$7K |
| D9222 |
|
40 |
40 |
$6K |
| D0603 |
|
909 |
907 |
$6K |
| D0274 |
Bitewings - four radiographic images |
488 |
488 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
62 |
62 |
$4K |
| D0350 |
|
503 |
336 |
$3K |
| D0602 |
|
218 |
218 |
$1K |