| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
132 |
116 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
248 |
246 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
86 |
85 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
28 |
12 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
109 |
57 |
$683.41 |
| D1120 |
Prophylaxis - child |
296 |
293 |
$677.10 |
| D1351 |
Sealant - per tooth |
40 |
15 |
$467.50 |
| D0220 |
Intraoral - periapical first radiographic image |
128 |
122 |
$459.49 |
| D0272 |
Bitewings - two radiographic images |
202 |
202 |
$450.79 |
| D0330 |
Panoramic radiographic image |
74 |
74 |
$282.83 |
| D0230 |
Intraoral - periapical each additional radiographic image |
69 |
65 |
$161.86 |
| D1208 |
Topical application of fluoride, excluding varnish |
116 |
114 |
$127.53 |
| D0240 |
|
70 |
68 |
$112.83 |
| D1206 |
Topical application of fluoride varnish |
213 |
211 |
$101.38 |
| D1330 |
|
342 |
339 |
$99.74 |
| D1110 |
Prophylaxis - adult |
25 |
25 |
$91.56 |
| D0274 |
Bitewings - four radiographic images |
28 |
28 |
$0.00 |
| D1999 |
|
23 |
23 |
$0.00 |