| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,452 |
1,315 |
$224K |
| D1120 |
Prophylaxis - child |
3,688 |
3,686 |
$148K |
| D0120 |
Periodic oral evaluation - established patient |
3,418 |
3,416 |
$98K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
786 |
224 |
$84K |
| D1206 |
Topical application of fluoride varnish |
2,967 |
2,966 |
$81K |
| D0274 |
Bitewings - four radiographic images |
1,794 |
1,794 |
$69K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
663 |
413 |
$53K |
| D1351 |
Sealant - per tooth |
1,298 |
513 |
$47K |
| D1110 |
Prophylaxis - adult |
800 |
800 |
$40K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,546 |
1,546 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
685 |
685 |
$20K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
128 |
77 |
$10K |
| D0240 |
|
447 |
241 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
94 |
45 |
$7K |
| D0330 |
Panoramic radiographic image |
137 |
137 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
141 |
78 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
112 |
82 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
349 |
343 |
$5K |
| D2140 |
|
57 |
42 |
$3K |
| D9310 |
|
77 |
77 |
$2K |
| D0272 |
Bitewings - two radiographic images |
79 |
79 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
151 |
71 |
$1K |
| D1353 |
|
52 |
24 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
23 |
23 |
$655.50 |
| D9996 |
|
92 |
92 |
$0.00 |
| D3120 |
|
131 |
83 |
$0.00 |