| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
79 |
38 |
$4K |
| D1110 |
Prophylaxis - adult |
92 |
92 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
67 |
67 |
$2K |
| D1351 |
Sealant - per tooth |
45 |
14 |
$924.00 |
| D0120 |
Periodic oral evaluation - established patient |
54 |
54 |
$888.16 |
| D0274 |
Bitewings - four radiographic images |
45 |
45 |
$880.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
43 |
43 |
$630.00 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
13 |
$338.70 |