| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
102 |
51 |
$12K |
| D1120 |
Prophylaxis - child |
254 |
252 |
$9K |
| D1110 |
Prophylaxis - adult |
166 |
166 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
332 |
330 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
206 |
204 |
$4K |
| D0274 |
Bitewings - four radiographic images |
57 |
57 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
14 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
29 |
$1K |
| D1351 |
Sealant - per tooth |
43 |
12 |
$844.00 |
| D1206 |
Topical application of fluoride varnish |
26 |
26 |
$650.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$250.00 |