| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
394 |
143 |
$47K |
| D1120 |
Prophylaxis - child |
609 |
609 |
$24K |
| D1206 |
Topical application of fluoride varnish |
859 |
858 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
750 |
749 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
700 |
676 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
106 |
54 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
959 |
634 |
$9K |
| D1110 |
Prophylaxis - adult |
68 |
68 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
74 |
72 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
57 |
57 |
$3K |
| D0274 |
Bitewings - four radiographic images |
59 |
59 |
$2K |
| D1351 |
Sealant - per tooth |
39 |
13 |
$990.00 |