| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
43 |
17 |
$3K |
| D1351 |
Sealant - per tooth |
96 |
12 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
51 |
48 |
$1K |
| D0274 |
Bitewings - four radiographic images |
41 |
39 |
$1K |
| D1110 |
Prophylaxis - adult |
17 |
15 |
$823.20 |
| D1208 |
Topical application of fluoride, excluding varnish |
56 |
53 |
$704.13 |
| D0220 |
Intraoral - periapical first radiographic image |
53 |
51 |
$601.62 |
| D0230 |
Intraoral - periapical each additional radiographic image |
53 |
49 |
$540.27 |
| D1120 |
Prophylaxis - child |
17 |
16 |
$514.50 |
| D0350 |
|
31 |
29 |
$257.32 |
| D0602 |
|
44 |
43 |
$0.00 |