| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
191 |
113 |
$24K |
| D1120 |
Prophylaxis - child |
285 |
285 |
$11K |
| D1206 |
Topical application of fluoride varnish |
303 |
303 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
182 |
182 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
273 |
271 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
25 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
386 |
224 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
41 |
41 |
$2K |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$2K |
| D0272 |
Bitewings - two radiographic images |
47 |
47 |
$1K |
| D1351 |
Sealant - per tooth |
38 |
14 |
$1K |