| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
606 |
370 |
$74K |
| D1120 |
Prophylaxis - child |
689 |
689 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
880 |
879 |
$24K |
| D1110 |
Prophylaxis - adult |
264 |
264 |
$14K |
| D1206 |
Topical application of fluoride varnish |
568 |
568 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
603 |
599 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
104 |
80 |
$10K |
| D0274 |
Bitewings - four radiographic images |
277 |
277 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
205 |
205 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
520 |
507 |
$4K |
| D1351 |
Sealant - per tooth |
61 |
14 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
40 |
40 |
$2K |
| D0272 |
Bitewings - two radiographic images |
49 |
49 |
$1K |