| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,707 |
331 |
$351K |
| D1120 |
Prophylaxis - child |
4,014 |
3,982 |
$163K |
| D7140 |
Extraction, erupted tooth or exposed root |
865 |
295 |
$117K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
734 |
125 |
$100K |
| D0120 |
Periodic oral evaluation - established patient |
2,693 |
2,676 |
$82K |
| D1206 |
Topical application of fluoride varnish |
4,055 |
3,969 |
$81K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
599 |
347 |
$50K |
| D1351 |
Sealant - per tooth |
1,289 |
459 |
$43K |
| D0220 |
Intraoral - periapical first radiographic image |
1,611 |
1,584 |
$40K |
| D0272 |
Bitewings - two radiographic images |
1,828 |
1,824 |
$38K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
789 |
738 |
$25K |
| D9222 |
|
125 |
125 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,800 |
945 |
$22K |
| D0603 |
|
3,302 |
3,285 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
383 |
382 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
126 |
77 |
$11K |
| D9920 |
|
353 |
353 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
198 |
198 |
$5K |
| D1110 |
Prophylaxis - adult |
64 |
64 |
$4K |
| D1354 |
|
823 |
227 |
$3K |
| D9248 |
|
28 |
27 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
136 |
132 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
89 |
85 |
$3K |
| D1999 |
|
1,071 |
1,007 |
$3K |
| D0274 |
Bitewings - four radiographic images |
62 |
62 |
$2K |
| D0602 |
|
365 |
359 |
$2K |
| D1330 |
|
3,935 |
3,904 |
$2K |
| D0330 |
Panoramic radiographic image |
38 |
38 |
$2K |