| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,348 |
2,154 |
$108K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,192 |
1,109 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
1,075 |
967 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,397 |
1,265 |
$20K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
562 |
483 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
322 |
139 |
$17K |
| D0272 |
Bitewings - two radiographic images |
975 |
905 |
$16K |
| D1206 |
Topical application of fluoride varnish |
873 |
818 |
$14K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
101 |
40 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
116 |
56 |
$5K |
| D0330 |
Panoramic radiographic image |
107 |
100 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
385 |
359 |
$4K |
| D1351 |
Sealant - per tooth |
203 |
70 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
100 |
35 |
$517.73 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
16 |
$343.20 |