| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
172 |
76 |
$15K |
| D1120 |
Prophylaxis - child |
509 |
509 |
$15K |
| D1351 |
Sealant - per tooth |
601 |
192 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
293 |
293 |
$8K |
| D1206 |
Topical application of fluoride varnish |
555 |
554 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
103 |
52 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
259 |
259 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
349 |
349 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
566 |
344 |
$4K |
| D0272 |
Bitewings - two radiographic images |
218 |
218 |
$4K |
| D0274 |
Bitewings - four radiographic images |
48 |
48 |
$1K |
| D1110 |
Prophylaxis - adult |
28 |
28 |
$1K |