| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
757 |
716 |
$50K |
| D1120 |
Prophylaxis - child |
1,301 |
1,301 |
$49K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
576 |
331 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
939 |
939 |
$24K |
| D1206 |
Topical application of fluoride varnish |
764 |
764 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
509 |
509 |
$14K |
| D1351 |
Sealant - per tooth |
387 |
139 |
$13K |
| D0274 |
Bitewings - four radiographic images |
221 |
221 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
141 |
100 |
$7K |
| D0272 |
Bitewings - two radiographic images |
360 |
360 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
396 |
396 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
118 |
69 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
56 |
42 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
49 |
29 |
$5K |
| D1110 |
Prophylaxis - adult |
110 |
110 |
$5K |
| D0330 |
Panoramic radiographic image |
74 |
74 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
22 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
74 |
73 |
$1K |
| D0240 |
|
34 |
31 |
$547.91 |