| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
110 |
71 |
$12K |
| D1120 |
Prophylaxis - child |
267 |
267 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
242 |
242 |
$8K |
| D1206 |
Topical application of fluoride varnish |
266 |
266 |
$7K |
| D0330 |
Panoramic radiographic image |
85 |
85 |
$7K |
| D1351 |
Sealant - per tooth |
86 |
33 |
$3K |
| D0274 |
Bitewings - four radiographic images |
57 |
57 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
16 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
30 |
30 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
14 |
$2K |
| D0272 |
Bitewings - two radiographic images |
43 |
43 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
61 |
59 |
$1K |
| D0240 |
|
43 |
43 |
$800.66 |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
16 |
$297.92 |