| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
97 |
47 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
235 |
233 |
$7K |
| D1120 |
Prophylaxis - child |
104 |
102 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
261 |
257 |
$4K |
| D0274 |
Bitewings - four radiographic images |
106 |
105 |
$3K |
| D1110 |
Prophylaxis - adult |
59 |
59 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
251 |
248 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
227 |
222 |
$3K |
| D1351 |
Sealant - per tooth |
56 |
16 |
$2K |
| D0272 |
Bitewings - two radiographic images |
46 |
46 |
$1K |
| D0603 |
|
312 |
308 |
$0.00 |