| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,422 |
4,268 |
$190K |
| D0120 |
Periodic oral evaluation - established patient |
5,613 |
5,383 |
$158K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,667 |
4,475 |
$116K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
745 |
356 |
$59K |
| D1110 |
Prophylaxis - adult |
1,658 |
1,577 |
$52K |
| D0274 |
Bitewings - four radiographic images |
1,534 |
1,461 |
$48K |
| D2991 |
|
344 |
60 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
575 |
480 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
712 |
670 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
254 |
241 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,064 |
997 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
183 |
86 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
702 |
462 |
$10K |
| D1206 |
Topical application of fluoride varnish |
368 |
355 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
65 |
29 |
$8K |
| D0272 |
Bitewings - two radiographic images |
266 |
253 |
$8K |
| D0330 |
Panoramic radiographic image |
143 |
125 |
$8K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
26 |
26 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
42 |
13 |
$4K |
| D1351 |
Sealant - per tooth |
111 |
31 |
$4K |
| D9222 |
|
26 |
26 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
12 |
12 |
$693.84 |