| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
234 |
142 |
$13K |
| D1110 |
Prophylaxis - adult |
225 |
225 |
$10K |
| D1206 |
Topical application of fluoride varnish |
310 |
310 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
299 |
299 |
$7K |
| D1120 |
Prophylaxis - child |
113 |
113 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
72 |
51 |
$5K |
| D1351 |
Sealant - per tooth |
208 |
41 |
$4K |
| D0274 |
Bitewings - four radiographic images |
205 |
205 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
102 |
102 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
291 |
290 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
235 |
235 |
$1K |
| D0603 |
|
99 |
99 |
$990.00 |
| D0272 |
Bitewings - two radiographic images |
36 |
36 |
$360.00 |
| D1330 |
|
21 |
21 |
$0.00 |