| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
218 |
129 |
$30K |
| D1110 |
Prophylaxis - adult |
490 |
490 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
196 |
112 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
625 |
625 |
$14K |
| D0274 |
Bitewings - four radiographic images |
278 |
278 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
547 |
543 |
$7K |
| D1120 |
Prophylaxis - child |
186 |
186 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
437 |
437 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
261 |
261 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
67 |
67 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
81 |
72 |
$2K |
| D1351 |
Sealant - per tooth |
34 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
30 |
30 |
$597.10 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$426.53 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$246.07 |