| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
646 |
624 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
544 |
529 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,350 |
725 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
424 |
402 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
250 |
215 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
92 |
64 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
227 |
210 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
802 |
766 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
54 |
35 |
$4K |
| D1351 |
Sealant - per tooth |
49 |
20 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
31 |
22 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
39 |
34 |
$1K |