| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
474 |
115 |
$52K |
| D1351 |
Sealant - per tooth |
2,027 |
425 |
$46K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
416 |
193 |
$28K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
150 |
68 |
$27K |
| D2390 |
|
208 |
42 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
391 |
203 |
$25K |
| D1120 |
Prophylaxis - child |
829 |
808 |
$22K |
| D7140 |
Extraction, erupted tooth or exposed root |
241 |
99 |
$18K |
| D0330 |
Panoramic radiographic image |
377 |
369 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
597 |
590 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
720 |
653 |
$11K |
| D1206 |
Topical application of fluoride varnish |
692 |
654 |
$11K |
| D0240 |
|
698 |
352 |
$10K |
| D0272 |
Bitewings - two radiographic images |
459 |
449 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
269 |
251 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
821 |
273 |
$6K |
| D9222 |
|
73 |
68 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
291 |
269 |
$5K |
| D0274 |
Bitewings - four radiographic images |
216 |
212 |
$5K |
| D1110 |
Prophylaxis - adult |
121 |
118 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
131 |
125 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
337 |
323 |
$4K |
| D2330 |
|
25 |
12 |
$2K |
| D9610 |
|
72 |
68 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
22 |
20 |
$551.00 |