| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
330 |
75 |
$29K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
235 |
49 |
$24K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
40 |
40 |
$16K |
| D9222 |
|
40 |
40 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
127 |
83 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
360 |
350 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
265 |
265 |
$5K |
| D1206 |
Topical application of fluoride varnish |
281 |
281 |
$5K |
| D0330 |
Panoramic radiographic image |
139 |
138 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
210 |
209 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
56 |
46 |
$4K |
| D0274 |
Bitewings - four radiographic images |
129 |
128 |
$3K |
| D1310 |
|
295 |
294 |
$3K |
| D1330 |
|
281 |
280 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
392 |
391 |
$3K |
| D0272 |
Bitewings - two radiographic images |
170 |
170 |
$3K |
| D1110 |
Prophylaxis - adult |
69 |
68 |
$2K |
| D1120 |
Prophylaxis - child |
71 |
71 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$1K |
| D1351 |
Sealant - per tooth |
45 |
12 |
$1K |