| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
461 |
261 |
$53K |
| D1120 |
Prophylaxis - child |
898 |
897 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,125 |
1,123 |
$30K |
| D1206 |
Topical application of fluoride varnish |
1,138 |
1,137 |
$29K |
| D1110 |
Prophylaxis - adult |
445 |
445 |
$23K |
| D1351 |
Sealant - per tooth |
694 |
108 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
102 |
71 |
$9K |
| D0274 |
Bitewings - four radiographic images |
260 |
260 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
428 |
424 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
113 |
113 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
54 |
54 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
259 |
257 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$1K |
| D0272 |
Bitewings - two radiographic images |
29 |
29 |
$693.00 |