| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
373 |
252 |
$47K |
| D1120 |
Prophylaxis - child |
846 |
846 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
843 |
840 |
$28K |
| D1206 |
Topical application of fluoride varnish |
923 |
922 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
223 |
165 |
$22K |
| D1351 |
Sealant - per tooth |
455 |
142 |
$14K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
64 |
29 |
$14K |
| D0272 |
Bitewings - two radiographic images |
417 |
416 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
141 |
139 |
$3K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$2K |
| D1110 |
Prophylaxis - adult |
34 |
34 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$837.75 |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$565.87 |