| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
112 |
45 |
$10K |
| D1351 |
Sealant - per tooth |
262 |
50 |
$6K |
| D1120 |
Prophylaxis - child |
177 |
160 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
164 |
150 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
214 |
194 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
213 |
115 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
97 |
92 |
$2K |
| D1206 |
Topical application of fluoride varnish |
116 |
100 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
13 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
90 |
86 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
25 |
$847.68 |
| D1110 |
Prophylaxis - adult |
13 |
12 |
$658.56 |
| D0274 |
Bitewings - four radiographic images |
17 |
16 |
$519.15 |
| D0603 |
|
373 |
346 |
$0.00 |