| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
150 |
90 |
$9K |
| D1110 |
Prophylaxis - adult |
230 |
230 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
419 |
419 |
$8K |
| D8670 |
Periodic orthodontic treatment visit |
71 |
71 |
$8K |
| D0274 |
Bitewings - four radiographic images |
269 |
268 |
$7K |
| D0330 |
Panoramic radiographic image |
168 |
166 |
$5K |
| D1351 |
Sealant - per tooth |
151 |
16 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
68 |
38 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
149 |
149 |
$3K |
| D1310 |
|
231 |
231 |
$3K |
| D1330 |
|
205 |
205 |
$2K |
| D1120 |
Prophylaxis - child |
75 |
75 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
226 |
223 |
$1K |
| D1206 |
Topical application of fluoride varnish |
62 |
62 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
34 |
34 |
$633.60 |
| D0272 |
Bitewings - two radiographic images |
17 |
17 |
$240.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
21 |
19 |
$152.00 |