| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
131 |
122 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
162 |
86 |
$15K |
| D1351 |
Sealant - per tooth |
180 |
82 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
61 |
41 |
$8K |
| D1120 |
Prophylaxis - child |
154 |
154 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
151 |
151 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
78 |
57 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
51 |
29 |
$4K |
| D0330 |
Panoramic radiographic image |
90 |
90 |
$3K |
| D1206 |
Topical application of fluoride varnish |
95 |
95 |
$3K |
| D0274 |
Bitewings - four radiographic images |
62 |
62 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
75 |
75 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
25 |
25 |
$852.02 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$736.60 |
| D0272 |
Bitewings - two radiographic images |
36 |
36 |
$712.30 |
| D0220 |
Intraoral - periapical first radiographic image |
62 |
60 |
$689.43 |
| D0140 |
Limited oral evaluation - problem focused |
31 |
31 |
$133.00 |