| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
10,013 |
9,935 |
$295K |
| D1208 |
Topical application of fluoride, excluding varnish |
15,284 |
15,154 |
$275K |
| D0120 |
Periodic oral evaluation - established patient |
14,045 |
13,922 |
$244K |
| D1110 |
Prophylaxis - adult |
5,142 |
5,085 |
$202K |
| D7240 |
Removal of impacted tooth - completely bony |
733 |
206 |
$174K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,902 |
997 |
$161K |
| D9920 |
|
1,711 |
1,641 |
$100K |
| D0272 |
Bitewings - two radiographic images |
5,195 |
5,145 |
$91K |
| D0220 |
Intraoral - periapical first radiographic image |
7,629 |
7,530 |
$73K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,225 |
6,989 |
$69K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
735 |
460 |
$49K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
444 |
221 |
$29K |
| D0274 |
Bitewings - four radiographic images |
1,029 |
1,013 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
318 |
201 |
$19K |
| D9222 |
|
219 |
219 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
435 |
433 |
$12K |
| D9994 |
|
3,509 |
3,465 |
$11K |
| D1351 |
Sealant - per tooth |
426 |
152 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
321 |
321 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
63 |
63 |
$4K |
| D0330 |
Panoramic radiographic image |
22 |
22 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
41 |
41 |
$975.06 |