| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
56 |
41 |
$4K |
| D1110 |
Prophylaxis - adult |
98 |
98 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
144 |
144 |
$3K |
| D1120 |
Prophylaxis - child |
73 |
73 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
182 |
182 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
174 |
174 |
$1K |
| D1351 |
Sealant - per tooth |
44 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
61 |
61 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
98 |
98 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$175.00 |