| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
714 |
661 |
$47K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
425 |
371 |
$31K |
| D1354 |
|
965 |
615 |
$28K |
| D1120 |
Prophylaxis - child |
643 |
643 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
943 |
929 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
313 |
274 |
$19K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
109 |
104 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
718 |
717 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,159 |
1,008 |
$17K |
| D1351 |
Sealant - per tooth |
209 |
164 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
327 |
327 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
184 |
174 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
81 |
76 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,173 |
1,157 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
35 |
29 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
152 |
150 |
$3K |
| D2940 |
|
31 |
28 |
$531.10 |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$403.88 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$376.67 |
| D0272 |
Bitewings - two radiographic images |
30 |
30 |
$321.61 |