| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
156 |
154 |
$7K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
65 |
49 |
$4K |
| D1120 |
Prophylaxis - child |
101 |
101 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
41 |
30 |
$3K |
| D1206 |
Topical application of fluoride varnish |
127 |
127 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
105 |
105 |
$2K |
| D1351 |
Sealant - per tooth |
62 |
17 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
30 |
19 |
$2K |
| D0272 |
Bitewings - two radiographic images |
74 |
74 |
$1K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
14 |
13 |
$1K |
| D1110 |
Prophylaxis - adult |
28 |
28 |
$1K |
| D2140 |
|
21 |
16 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
13 |
$981.60 |
| D0274 |
Bitewings - four radiographic images |
27 |
27 |
$856.44 |
| D1330 |
|
120 |
120 |
$600.00 |
| D0603 |
|
53 |
53 |
$545.90 |
| D0602 |
|
49 |
49 |
$504.70 |
| D0220 |
Intraoral - periapical first radiographic image |
49 |
49 |
$443.94 |
| D0230 |
Intraoral - periapical each additional radiographic image |
37 |
37 |
$353.34 |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$294.58 |