| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
80 |
39 |
$10K |
| D1120 |
Prophylaxis - child |
232 |
232 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
92 |
48 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
141 |
141 |
$6K |
| D1351 |
Sealant - per tooth |
201 |
68 |
$6K |
| D1206 |
Topical application of fluoride varnish |
241 |
241 |
$6K |
| D0274 |
Bitewings - four radiographic images |
110 |
110 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
110 |
110 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
107 |
107 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
119 |
98 |
$1K |
| D0272 |
Bitewings - two radiographic images |
40 |
40 |
$975.00 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$702.00 |