| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
102 |
37 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
467 |
238 |
$5K |
| D1351 |
Sealant - per tooth |
182 |
34 |
$4K |
| D0274 |
Bitewings - four radiographic images |
171 |
165 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
141 |
139 |
$4K |
| D1120 |
Prophylaxis - child |
110 |
108 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
229 |
224 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
253 |
245 |
$3K |
| D1110 |
Prophylaxis - adult |
36 |
36 |
$2K |
| D0350 |
|
44 |
32 |
$477.88 |
| D0603 |
|
234 |
231 |
$0.00 |