| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
797 |
792 |
$20K |
| D1120 |
Prophylaxis - child |
579 |
575 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
138 |
69 |
$13K |
| D1206 |
Topical application of fluoride varnish |
832 |
827 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
138 |
70 |
$11K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
78 |
13 |
$11K |
| D1110 |
Prophylaxis - adult |
240 |
240 |
$9K |
| D0272 |
Bitewings - two radiographic images |
315 |
311 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
71 |
64 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
46 |
26 |
$3K |
| D9420 |
|
12 |
12 |
$1K |
| D1351 |
Sealant - per tooth |
29 |
12 |
$747.25 |