| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,561 |
1,429 |
$224K |
| D1120 |
Prophylaxis - child |
5,104 |
4,192 |
$113K |
| D0274 |
Bitewings - four radiographic images |
3,926 |
3,208 |
$64K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,567 |
3,758 |
$57K |
| D0120 |
Periodic oral evaluation - established patient |
2,138 |
1,913 |
$55K |
| D0330 |
Panoramic radiographic image |
1,237 |
1,064 |
$37K |
| D0140 |
Limited oral evaluation - problem focused |
899 |
795 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,029 |
1,495 |
$30K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
122 |
76 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
243 |
135 |
$16K |
| D1351 |
Sealant - per tooth |
652 |
183 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
73 |
56 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
152 |
143 |
$9K |
| D0272 |
Bitewings - two radiographic images |
269 |
193 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
111 |
87 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
59 |
29 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
172 |
159 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
108 |
100 |
$899.03 |