| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,056 |
626 |
$123K |
| D1120 |
Prophylaxis - child |
4,855 |
3,527 |
$94K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,226 |
2,060 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
1,601 |
1,419 |
$41K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,538 |
2,604 |
$40K |
| D0274 |
Bitewings - four radiographic images |
2,798 |
1,908 |
$36K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
297 |
44 |
$31K |
| D0210 |
Intraoral - complete series of radiographic images |
585 |
356 |
$24K |
| D0330 |
Panoramic radiographic image |
1,610 |
1,069 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
394 |
163 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
664 |
416 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
743 |
478 |
$13K |
| D1206 |
Topical application of fluoride varnish |
918 |
622 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
216 |
44 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,068 |
719 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
46 |
27 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
648 |
178 |
$3K |