| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
76 |
50 |
$10K |
| D0274 |
Bitewings - four radiographic images |
293 |
293 |
$9K |
| D1120 |
Prophylaxis - child |
218 |
218 |
$8K |
| D1206 |
Topical application of fluoride varnish |
297 |
297 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
190 |
190 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
61 |
47 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
125 |
125 |
$5K |
| D1110 |
Prophylaxis - adult |
83 |
83 |
$4K |
| D0330 |
Panoramic radiographic image |
53 |
53 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
46 |
45 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
95 |
95 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
15 |
$1K |
| D1351 |
Sealant - per tooth |
47 |
16 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
25 |
24 |
$918.94 |