| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
259 |
126 |
$30K |
| D1120 |
Prophylaxis - child |
196 |
196 |
$7K |
| D1110 |
Prophylaxis - adult |
144 |
144 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
153 |
153 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
233 |
233 |
$6K |
| D1206 |
Topical application of fluoride varnish |
255 |
255 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
47 |
30 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
231 |
231 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
35 |
35 |
$2K |
| D1351 |
Sealant - per tooth |
74 |
27 |
$2K |
| D0274 |
Bitewings - four radiographic images |
47 |
47 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
96 |
92 |
$750.00 |
| D0272 |
Bitewings - two radiographic images |
30 |
30 |
$648.00 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
15 |
$590.00 |