| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
334 |
333 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
436 |
435 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
443 |
442 |
$8K |
| D1351 |
Sealant - per tooth |
319 |
109 |
$8K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
14 |
14 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
49 |
16 |
$5K |
| D1110 |
Prophylaxis - adult |
126 |
126 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
64 |
37 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
31 |
13 |
$2K |
| D9222 |
|
14 |
14 |
$2K |
| D0274 |
Bitewings - four radiographic images |
62 |
62 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
18 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
42 |
42 |
$678.72 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
14 |
$622.60 |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$600.88 |
| D9110 |
|
15 |
15 |
$497.60 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
20 |
20 |
$401.80 |
| D0220 |
Intraoral - periapical first radiographic image |
38 |
38 |
$299.36 |
| D1206 |
Topical application of fluoride varnish |
16 |
16 |
$288.00 |