| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
115 |
70 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
181 |
181 |
$5K |
| D1206 |
Topical application of fluoride varnish |
133 |
133 |
$4K |
| D1120 |
Prophylaxis - child |
82 |
82 |
$4K |
| D1110 |
Prophylaxis - adult |
60 |
60 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
71 |
71 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$1K |
| D1351 |
Sealant - per tooth |
56 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
195 |
195 |
$975.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
165 |
165 |
$789.00 |
| D0272 |
Bitewings - two radiographic images |
40 |
40 |
$400.00 |
| D0603 |
|
37 |
37 |
$370.00 |
| D9920 |
|
12 |
12 |
$300.00 |
| D0602 |
|
21 |
21 |
$210.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$144.00 |