| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,936 |
1,864 |
$78K |
| D0120 |
Periodic oral evaluation - established patient |
2,041 |
1,962 |
$57K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
805 |
701 |
$40K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
370 |
247 |
$37K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,104 |
1,072 |
$29K |
| D1351 |
Sealant - per tooth |
160 |
70 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
109 |
64 |
$7K |
| D0274 |
Bitewings - four radiographic images |
276 |
271 |
$5K |
| D0272 |
Bitewings - two radiographic images |
287 |
282 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
81 |
68 |
$302.40 |
| D0230 |
Intraoral - periapical each additional radiographic image |
30 |
26 |
$76.00 |