| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
740 |
171 |
$138K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
187 |
85 |
$81K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
383 |
247 |
$57K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
495 |
298 |
$57K |
| D1120 |
Prophylaxis - child |
1,310 |
1,273 |
$56K |
| D1351 |
Sealant - per tooth |
1,353 |
405 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
1,231 |
1,191 |
$42K |
| D1206 |
Topical application of fluoride varnish |
1,673 |
1,625 |
$42K |
| D7140 |
Extraction, erupted tooth or exposed root |
470 |
231 |
$39K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,160 |
809 |
$37K |
| D0274 |
Bitewings - four radiographic images |
603 |
591 |
$27K |
| D1110 |
Prophylaxis - adult |
403 |
393 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
1,218 |
1,191 |
$25K |
| D0330 |
Panoramic radiographic image |
301 |
294 |
$23K |
| D2933 |
|
108 |
31 |
$22K |
| D9222 |
|
85 |
85 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
359 |
355 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
300 |
291 |
$15K |
| D0272 |
Bitewings - two radiographic images |
440 |
439 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
139 |
138 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
117 |
117 |
$4K |
| D2330 |
|
18 |
13 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$276.00 |