| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
327 |
327 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
192 |
139 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
384 |
384 |
$9K |
| D1206 |
Topical application of fluoride varnish |
253 |
253 |
$7K |
| D1120 |
Prophylaxis - child |
133 |
133 |
$5K |
| D0274 |
Bitewings - four radiographic images |
357 |
357 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
69 |
42 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
136 |
136 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
482 |
481 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
543 |
541 |
$3K |
| D1351 |
Sealant - per tooth |
144 |
25 |
$2K |
| D0603 |
|
200 |
200 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
45 |
45 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$523.00 |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$225.00 |