| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
839 |
839 |
$34K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
405 |
398 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
971 |
971 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
275 |
148 |
$22K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
136 |
54 |
$15K |
| D1206 |
Topical application of fluoride varnish |
500 |
500 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
361 |
361 |
$12K |
| D1351 |
Sealant - per tooth |
261 |
90 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
607 |
607 |
$9K |
| D0272 |
Bitewings - two radiographic images |
340 |
340 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
416 |
416 |
$6K |
| D1110 |
Prophylaxis - adult |
75 |
75 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
72 |
31 |
$4K |
| D0330 |
Panoramic radiographic image |
70 |
70 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
90 |
90 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
22 |
$2K |
| D0274 |
Bitewings - four radiographic images |
39 |
39 |
$1K |