| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
292 |
290 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
353 |
353 |
$13K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
57 |
14 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
79 |
45 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
165 |
157 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
235 |
235 |
$6K |
| D1351 |
Sealant - per tooth |
150 |
36 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
62 |
62 |
$5K |
| D1110 |
Prophylaxis - adult |
69 |
69 |
$4K |
| D1206 |
Topical application of fluoride varnish |
67 |
65 |
$2K |
| D0272 |
Bitewings - two radiographic images |
68 |
68 |
$2K |