| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
726 |
671 |
$30K |
| D1120 |
Prophylaxis - child |
587 |
545 |
$27K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
378 |
88 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
380 |
139 |
$17K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
234 |
48 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
318 |
302 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
213 |
183 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
194 |
165 |
$5K |
| D0272 |
Bitewings - two radiographic images |
332 |
305 |
$5K |
| D2929 |
|
54 |
12 |
$5K |
| D0330 |
Panoramic radiographic image |
167 |
149 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
51 |
13 |
$2K |
| D9222 |
|
49 |
47 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
276 |
132 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
15 |
$2K |
| D1351 |
Sealant - per tooth |
112 |
13 |
$1K |
| D1110 |
Prophylaxis - adult |
54 |
46 |
$960.82 |
| D0220 |
Intraoral - periapical first radiographic image |
99 |
87 |
$833.60 |
| D0145 |
Oral evaluation for a patient under three years of age |
43 |
41 |
$702.95 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
43 |
38 |
$425.60 |
| D0274 |
Bitewings - four radiographic images |
27 |
24 |
$282.84 |