| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
240 |
146 |
$19K |
| D1110 |
Prophylaxis - adult |
394 |
394 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
561 |
561 |
$11K |
| D0274 |
Bitewings - four radiographic images |
265 |
265 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
121 |
81 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
69 |
53 |
$6K |
| D4910 |
|
93 |
93 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
240 |
240 |
$5K |
| D1120 |
Prophylaxis - child |
139 |
139 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
160 |
160 |
$3K |
| D0330 |
Panoramic radiographic image |
54 |
54 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
85 |
85 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
240 |
240 |
$2K |
| D1351 |
Sealant - per tooth |
62 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
62 |
61 |
$2K |
| D0272 |
Bitewings - two radiographic images |
79 |
79 |
$1K |
| D1310 |
|
182 |
182 |
$1K |
| D1330 |
|
188 |
188 |
$994.72 |