| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
534 |
462 |
$4K |
| D9222 |
|
931 |
901 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
973 |
399 |
$328.00 |
| D1120 |
Prophylaxis - child |
1,131 |
1,118 |
$266.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
605 |
593 |
$186.00 |
| D0120 |
Periodic oral evaluation - established patient |
1,484 |
1,470 |
$182.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
66 |
26 |
$177.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,688 |
1,671 |
$162.00 |
| D1351 |
Sealant - per tooth |
1,172 |
337 |
$92.00 |
| D0220 |
Intraoral - periapical first radiographic image |
345 |
337 |
$60.00 |
| D0274 |
Bitewings - four radiographic images |
345 |
344 |
$52.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
116 |
53 |
$50.00 |
| D1110 |
Prophylaxis - adult |
248 |
247 |
$44.00 |
| D0272 |
Bitewings - two radiographic images |
583 |
574 |
$36.00 |
| D9248 |
|
214 |
212 |
$28.00 |
| D1999 |
|
375 |
368 |
$0.00 |
| D0330 |
Panoramic radiographic image |
72 |
71 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
116 |
71 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
20 |
12 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
57 |
57 |
$0.00 |
| D0240 |
|
62 |
33 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$0.00 |