| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
291 |
162 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
486 |
485 |
$12K |
| D1120 |
Prophylaxis - child |
196 |
196 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
65 |
40 |
$7K |
| D0274 |
Bitewings - four radiographic images |
416 |
415 |
$6K |
| D1351 |
Sealant - per tooth |
79 |
33 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
192 |
192 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
79 |
60 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
580 |
569 |
$3K |
| D4342 |
|
29 |
16 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
596 |
524 |
$3K |
| D0330 |
Panoramic radiographic image |
156 |
156 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
46 |
46 |
$1K |
| D1110 |
Prophylaxis - adult |
16 |
16 |
$725.70 |
| D0210 |
Intraoral - complete series of radiographic images |
86 |
84 |
$455.14 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
13 |
$286.80 |