| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1354 |
|
1,645 |
879 |
$45K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
621 |
569 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
486 |
397 |
$36K |
| D1120 |
Prophylaxis - child |
648 |
648 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,018 |
1,018 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,185 |
1,168 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,627 |
1,270 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
200 |
183 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
343 |
342 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,385 |
1,375 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
72 |
59 |
$7K |
| D1351 |
Sealant - per tooth |
87 |
60 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
31 |
31 |
$5K |
| D2940 |
|
295 |
219 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
101 |
92 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
142 |
142 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
30 |
30 |
$3K |
| D0274 |
Bitewings - four radiographic images |
43 |
43 |
$658.02 |
| D0272 |
Bitewings - two radiographic images |
56 |
56 |
$516.65 |