| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
191 |
106 |
$25K |
| D1351 |
Sealant - per tooth |
680 |
102 |
$20K |
| D1110 |
Prophylaxis - adult |
237 |
237 |
$13K |
| D1206 |
Topical application of fluoride varnish |
213 |
213 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
194 |
194 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
139 |
139 |
$5K |
| D0274 |
Bitewings - four radiographic images |
149 |
149 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
24 |
15 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
83 |
78 |
$4K |
| D1120 |
Prophylaxis - child |
86 |
86 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
30 |
30 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
111 |
109 |
$2K |
| D9110 |
|
16 |
15 |
$1K |