| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
486 |
241 |
$33K |
| D1110 |
Prophylaxis - adult |
492 |
490 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
242 |
151 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
529 |
528 |
$13K |
| D1206 |
Topical application of fluoride varnish |
292 |
289 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
82 |
48 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
274 |
273 |
$7K |
| D0274 |
Bitewings - four radiographic images |
404 |
402 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
557 |
545 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
579 |
575 |
$3K |
| D1120 |
Prophylaxis - child |
52 |
52 |
$2K |
| D1351 |
Sealant - per tooth |
70 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
54 |
53 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
19 |
19 |
$855.00 |
| D0603 |
|
158 |
158 |
$730.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$450.00 |
| D0272 |
Bitewings - two radiographic images |
17 |
17 |
$170.00 |