| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,472 |
1,470 |
$66K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
720 |
427 |
$50K |
| D1206 |
Topical application of fluoride varnish |
1,488 |
1,486 |
$46K |
| D1351 |
Sealant - per tooth |
2,324 |
587 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
1,304 |
1,302 |
$32K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
345 |
242 |
$19K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
745 |
736 |
$18K |
| D0272 |
Bitewings - two radiographic images |
838 |
837 |
$8K |
| D1353 |
|
804 |
212 |
$8K |
| D0603 |
|
675 |
675 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,323 |
1,321 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
42 |
27 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,267 |
1,265 |
$4K |
| D9920 |
|
137 |
135 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
62 |
42 |
$3K |
| D0274 |
Bitewings - four radiographic images |
169 |
168 |
$2K |