| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
786 |
749 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
738 |
702 |
$20K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
638 |
586 |
$16K |
| D1206 |
Topical application of fluoride varnish |
415 |
406 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
165 |
142 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
550 |
458 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
70 |
45 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
151 |
119 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
692 |
661 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
66 |
53 |
$3K |
| D1351 |
Sealant - per tooth |
60 |
24 |
$3K |
| D9310 |
|
115 |
115 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
69 |
64 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
53 |
53 |
$1K |
| D1999 |
|
24 |
22 |
$0.00 |
| D0601 |
|
32 |
32 |
$0.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
18 |
16 |
$0.00 |