| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
124 |
66 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
499 |
280 |
$10K |
| D1110 |
Prophylaxis - adult |
177 |
177 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
462 |
451 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
157 |
157 |
$8K |
| D0274 |
Bitewings - four radiographic images |
202 |
202 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
288 |
288 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
211 |
211 |
$3K |
| D1120 |
Prophylaxis - child |
97 |
97 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
40 |
39 |
$2K |
| D1206 |
Topical application of fluoride varnish |
53 |
53 |
$2K |
| D1351 |
Sealant - per tooth |
35 |
12 |
$789.60 |