| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
878 |
878 |
$37K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
197 |
166 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,130 |
1,130 |
$29K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
430 |
416 |
$25K |
| D1206 |
Topical application of fluoride varnish |
841 |
841 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
176 |
161 |
$13K |
| D1351 |
Sealant - per tooth |
144 |
110 |
$10K |
| D0272 |
Bitewings - two radiographic images |
778 |
778 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
88 |
76 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
920 |
918 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
170 |
170 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
817 |
816 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
76 |
73 |
$3K |
| D1354 |
|
96 |
74 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
54 |
54 |
$1K |