| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,879 |
1,870 |
$76K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
687 |
331 |
$73K |
| D1206 |
Topical application of fluoride varnish |
2,362 |
2,275 |
$65K |
| D0120 |
Periodic oral evaluation - established patient |
996 |
994 |
$27K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
379 |
368 |
$25K |
| D1351 |
Sealant - per tooth |
697 |
287 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
273 |
153 |
$24K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
124 |
68 |
$23K |
| D9920 |
|
120 |
119 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
167 |
72 |
$18K |
| D0603 |
|
1,148 |
1,146 |
$11K |
| D0272 |
Bitewings - two radiographic images |
476 |
475 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
164 |
161 |
$7K |
| D1330 |
|
1,164 |
1,162 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
409 |
394 |
$6K |
| D0240 |
|
176 |
160 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
173 |
160 |
$5K |
| D1310 |
|
705 |
704 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
22 |
14 |
$2K |
| D0330 |
Panoramic radiographic image |
32 |
31 |
$2K |