| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
212 |
131 |
$23K |
| D1110 |
Prophylaxis - adult |
311 |
311 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
492 |
492 |
$12K |
| D1120 |
Prophylaxis - child |
287 |
287 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
98 |
63 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
117 |
117 |
$8K |
| D1206 |
Topical application of fluoride varnish |
309 |
309 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
158 |
158 |
$6K |
| D0274 |
Bitewings - four radiographic images |
189 |
189 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
14 |
$2K |
| D1351 |
Sealant - per tooth |
45 |
14 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
30 |
29 |
$359.00 |