| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
234 |
202 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
480 |
465 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
430 |
425 |
$21K |
| D1120 |
Prophylaxis - child |
880 |
866 |
$15K |
| D1330 |
|
924 |
905 |
$13K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
178 |
95 |
$8K |
| D0272 |
Bitewings - two radiographic images |
474 |
468 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
79 |
51 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
106 |
100 |
$3K |
| D1999 |
|
43 |
42 |
$2K |
| D1351 |
Sealant - per tooth |
187 |
49 |
$2K |
| D0240 |
|
121 |
120 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
27 |
27 |
$1K |
| D9920 |
|
74 |
64 |
$666.05 |
| D7140 |
Extraction, erupted tooth or exposed root |
75 |
40 |
$622.55 |
| D0220 |
Intraoral - periapical first radiographic image |
351 |
321 |
$619.55 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
22 |
15 |
$590.10 |
| D0330 |
Panoramic radiographic image |
154 |
153 |
$441.10 |
| D0999 |
Unspecified diagnostic procedure, by report |
17 |
17 |
$340.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
485 |
478 |
$318.40 |
| D9995 |
|
12 |
12 |
$272.25 |
| D0602 |
|
499 |
496 |
$162.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
457 |
219 |
$133.20 |
| D1206 |
Topical application of fluoride varnish |
384 |
375 |
$16.00 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$0.00 |
| D0603 |
|
83 |
79 |
$0.00 |
| D0601 |
|
70 |
70 |
$0.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
19 |
19 |
$0.00 |