| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
343 |
343 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
118 |
85 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
359 |
359 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
130 |
127 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
54 |
47 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
235 |
235 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
91 |
47 |
$5K |
| D1351 |
Sealant - per tooth |
139 |
55 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
47 |
34 |
$3K |
| D0272 |
Bitewings - two radiographic images |
162 |
162 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
292 |
288 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
100 |
100 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
213 |
191 |
$2K |
| D1354 |
|
43 |
19 |
$290.00 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$278.72 |