| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
410 |
193 |
$25K |
| D1120 |
Prophylaxis - child |
396 |
341 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
411 |
342 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
153 |
74 |
$9K |
| D1351 |
Sealant - per tooth |
219 |
78 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
204 |
91 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
298 |
249 |
$8K |
| D0274 |
Bitewings - four radiographic images |
325 |
248 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
189 |
128 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
538 |
408 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
524 |
377 |
$2K |
| D1206 |
Topical application of fluoride varnish |
64 |
60 |
$2K |
| D1110 |
Prophylaxis - adult |
70 |
39 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
15 |
$1K |
| D0272 |
Bitewings - two radiographic images |
70 |
56 |
$629.80 |
| D0140 |
Limited oral evaluation - problem focused |
22 |
17 |
$324.00 |