| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
126 |
79 |
$16K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
69 |
53 |
$13K |
| D1120 |
Prophylaxis - child |
271 |
268 |
$11K |
| D1206 |
Topical application of fluoride varnish |
272 |
269 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
68 |
41 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
77 |
52 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
187 |
185 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
91 |
91 |
$6K |
| D0272 |
Bitewings - two radiographic images |
85 |
84 |
$2K |
| D1351 |
Sealant - per tooth |
70 |
30 |
$2K |
| D0240 |
|
102 |
50 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
110 |
110 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
126 |
70 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
17 |
17 |
$688.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$360.00 |