| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
430 |
413 |
$56K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
559 |
294 |
$40K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
292 |
149 |
$38K |
| D1351 |
Sealant - per tooth |
403 |
173 |
$19K |
| D1120 |
Prophylaxis - child |
376 |
376 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
215 |
145 |
$16K |
| D7240 |
Removal of impacted tooth - completely bony |
41 |
12 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
357 |
357 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
93 |
71 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
138 |
99 |
$8K |
| D1206 |
Topical application of fluoride varnish |
252 |
252 |
$7K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
69 |
49 |
$6K |
| D0330 |
Panoramic radiographic image |
118 |
118 |
$5K |
| D0274 |
Bitewings - four radiographic images |
147 |
147 |
$5K |
| D0272 |
Bitewings - two radiographic images |
170 |
170 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
97 |
97 |
$3K |
| D9310 |
|
43 |
43 |
$3K |
| D2332 |
|
15 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
90 |
88 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
84 |
84 |
$1K |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$732.04 |