| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
171 |
101 |
$19K |
| D1110 |
Prophylaxis - adult |
253 |
252 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
221 |
220 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
139 |
139 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
52 |
34 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
65 |
65 |
$5K |
| D0274 |
Bitewings - four radiographic images |
128 |
128 |
$5K |
| D0330 |
Panoramic radiographic image |
65 |
64 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
32 |
27 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
171 |
171 |
$2K |
| D1351 |
Sealant - per tooth |
64 |
12 |
$2K |
| D1206 |
Topical application of fluoride varnish |
120 |
119 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
60 |
60 |
$972.00 |
| D0270 |
|
55 |
55 |
$757.60 |
| D9110 |
|
22 |
22 |
$723.00 |