| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
373 |
205 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
292 |
164 |
$20K |
| D1120 |
Prophylaxis - child |
607 |
585 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
784 |
762 |
$18K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
163 |
37 |
$17K |
| D1206 |
Topical application of fluoride varnish |
622 |
598 |
$13K |
| D1110 |
Prophylaxis - adult |
317 |
307 |
$13K |
| D0330 |
Panoramic radiographic image |
286 |
273 |
$10K |
| D1351 |
Sealant - per tooth |
307 |
89 |
$8K |
| D0274 |
Bitewings - four radiographic images |
381 |
371 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
223 |
219 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
82 |
29 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
155 |
148 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
347 |
79 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
225 |
207 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
15 |
$2K |
| D0272 |
Bitewings - two radiographic images |
44 |
44 |
$754.18 |
| D0140 |
Limited oral evaluation - problem focused |
17 |
17 |
$373.35 |