| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
53 |
28 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
106 |
105 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
61 |
28 |
$6K |
| D1120 |
Prophylaxis - child |
104 |
102 |
$4K |
| D9920 |
|
65 |
62 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
21 |
12 |
$4K |
| D0240 |
|
143 |
73 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
221 |
108 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
125 |
119 |
$2K |
| D1206 |
Topical application of fluoride varnish |
83 |
83 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
30 |
29 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$1K |