| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
106 |
73 |
$10K |
| D1351 |
Sealant - per tooth |
358 |
91 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
166 |
163 |
$6K |
| D1110 |
Prophylaxis - adult |
77 |
77 |
$4K |
| D1120 |
Prophylaxis - child |
118 |
117 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
381 |
257 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
263 |
260 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
48 |
37 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
267 |
263 |
$3K |
| D0274 |
Bitewings - four radiographic images |
77 |
77 |
$3K |
| D0272 |
Bitewings - two radiographic images |
75 |
74 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
36 |
36 |
$1K |
| D0603 |
|
286 |
286 |
$0.00 |