| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,648 |
2,646 |
$92K |
| D0120 |
Periodic oral evaluation - established patient |
3,240 |
3,240 |
$75K |
| D1206 |
Topical application of fluoride varnish |
2,065 |
2,062 |
$45K |
| 88305 |
Level IV - Surgical pathology, gross and microscopic examination |
532 |
531 |
$42K |
| D1110 |
Prophylaxis - adult |
836 |
836 |
$38K |
| D7140 |
Extraction, erupted tooth or exposed root |
762 |
370 |
$26K |
| D9310 |
|
509 |
509 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
422 |
305 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,359 |
1,359 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
396 |
274 |
$14K |
| D0330 |
Panoramic radiographic image |
371 |
371 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
424 |
415 |
$11K |
| D0272 |
Bitewings - two radiographic images |
866 |
865 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
417 |
415 |
$10K |
| D1354 |
|
681 |
173 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
124 |
69 |
$9K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
134 |
56 |
$8K |
| D0274 |
Bitewings - four radiographic images |
375 |
375 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
466 |
457 |
$5K |
| D1351 |
Sealant - per tooth |
153 |
53 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
357 |
354 |
$4K |
| D0340 |
|
34 |
34 |
$2K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
13 |
13 |
$1K |
| D9222 |
|
13 |
13 |
$567.60 |
| D0350 |
|
32 |
32 |
$369.66 |
| D0470 |
|
12 |
12 |
$359.59 |
| D0240 |
|
14 |
14 |
$190.70 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$160.93 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$110.41 |