| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
71 |
28 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
203 |
200 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
245 |
204 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
175 |
174 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
208 |
205 |
$2K |
| D1120 |
Prophylaxis - child |
52 |
52 |
$2K |
| D1351 |
Sealant - per tooth |
88 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
51 |
51 |
$1K |
| D1110 |
Prophylaxis - adult |
19 |
19 |
$878.08 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$706.40 |
| D0601 |
|
12 |
12 |
$0.00 |
| D0603 |
|
41 |
40 |
$0.00 |