| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
548 |
548 |
$24K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
243 |
237 |
$16K |
| D1206 |
Topical application of fluoride varnish |
498 |
498 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
456 |
456 |
$13K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
75 |
63 |
$9K |
| D1351 |
Sealant - per tooth |
149 |
77 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
86 |
74 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
104 |
83 |
$5K |
| D0272 |
Bitewings - two radiographic images |
320 |
320 |
$4K |
| D0274 |
Bitewings - four radiographic images |
137 |
137 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
346 |
346 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
92 |
92 |
$3K |
| D0330 |
Panoramic radiographic image |
107 |
107 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
38 |
32 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
265 |
265 |
$2K |