| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
119 |
58 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
69 |
36 |
$6K |
| D1120 |
Prophylaxis - child |
91 |
91 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
108 |
108 |
$3K |
| D1206 |
Topical application of fluoride varnish |
109 |
109 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
48 |
47 |
$2K |
| D1110 |
Prophylaxis - adult |
29 |
29 |
$2K |
| D0274 |
Bitewings - four radiographic images |
41 |
41 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
33 |
32 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
76 |
75 |
$1K |
| D1351 |
Sealant - per tooth |
38 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$936.00 |