| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
386 |
372 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,145 |
1,130 |
$43K |
| D0330 |
Panoramic radiographic image |
308 |
305 |
$37K |
| D1110 |
Prophylaxis - adult |
445 |
441 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
136 |
136 |
$9K |
| D1351 |
Sealant - per tooth |
823 |
257 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
301 |
203 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
223 |
128 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
90 |
64 |
$978.02 |
| D0140 |
Limited oral evaluation - problem focused |
44 |
44 |
$808.74 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
46 |
37 |
$698.56 |
| D0220 |
Intraoral - periapical first radiographic image |
557 |
552 |
$531.70 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,186 |
1,170 |
$444.05 |
| D1330 |
|
1,306 |
1,290 |
$345.16 |
| D1120 |
Prophylaxis - child |
809 |
802 |
$333.04 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
103 |
72 |
$148.64 |
| D0272 |
Bitewings - two radiographic images |
418 |
417 |
$105.55 |
| D0274 |
Bitewings - four radiographic images |
145 |
140 |
$90.45 |
| D0230 |
Intraoral - periapical each additional radiographic image |
398 |
393 |
$50.60 |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
16 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
16 |
16 |
$0.00 |
| D3120 |
|
14 |
13 |
$0.00 |