| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
291 |
140 |
$25K |
| D1110 |
Prophylaxis - adult |
146 |
146 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
272 |
272 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
314 |
314 |
$4K |
| D1120 |
Prophylaxis - child |
145 |
145 |
$4K |
| D0274 |
Bitewings - four radiographic images |
137 |
137 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
45 |
27 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
56 |
54 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
65 |
63 |
$915.76 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$586.30 |
| D1351 |
Sealant - per tooth |
24 |
12 |
$541.44 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$338.40 |