| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,259 |
2,259 |
$88K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
589 |
185 |
$80K |
| D1206 |
Topical application of fluoride varnish |
2,867 |
2,861 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
1,999 |
1,993 |
$53K |
| D0350 |
|
966 |
347 |
$51K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
104 |
91 |
$50K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
410 |
186 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
809 |
802 |
$36K |
| D9310 |
|
695 |
689 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
893 |
892 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
199 |
81 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,424 |
1,399 |
$18K |
| D1110 |
Prophylaxis - adult |
313 |
312 |
$17K |
| D0272 |
Bitewings - two radiographic images |
772 |
772 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
100 |
49 |
$14K |
| D0240 |
|
487 |
486 |
$13K |
| D9222 |
|
103 |
90 |
$11K |
| D0330 |
Panoramic radiographic image |
175 |
175 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
223 |
210 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
160 |
159 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
132 |
128 |
$3K |
| D3120 |
|
43 |
27 |
$2K |
| D0274 |
Bitewings - four radiographic images |
43 |
43 |
$1K |