| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
801 |
348 |
$58K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
406 |
135 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
1,288 |
1,277 |
$31K |
| D1120 |
Prophylaxis - child |
1,131 |
1,122 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
417 |
165 |
$24K |
| D1351 |
Sealant - per tooth |
1,987 |
451 |
$23K |
| D1206 |
Topical application of fluoride varnish |
1,511 |
1,494 |
$22K |
| D0330 |
Panoramic radiographic image |
315 |
313 |
$15K |
| D1110 |
Prophylaxis - adult |
409 |
402 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
396 |
387 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
284 |
279 |
$11K |
| D9420 |
|
83 |
77 |
$8K |
| D0272 |
Bitewings - two radiographic images |
437 |
433 |
$7K |
| D0274 |
Bitewings - four radiographic images |
89 |
88 |
$3K |
| D7111 |
|
34 |
24 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14 |
12 |
$1K |
| D0240 |
|
24 |
12 |
$334.18 |