| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
202 |
65 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
92 |
44 |
$9K |
| D1120 |
Prophylaxis - child |
97 |
88 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
126 |
111 |
$3K |
| D1110 |
Prophylaxis - adult |
61 |
52 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
237 |
141 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
165 |
147 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
160 |
142 |
$2K |
| D0274 |
Bitewings - four radiographic images |
61 |
51 |
$2K |
| D1351 |
Sealant - per tooth |
42 |
17 |
$1K |
| D0272 |
Bitewings - two radiographic images |
21 |
21 |
$490.98 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$459.16 |
| D0603 |
|
196 |
173 |
$0.00 |