| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
307 |
123 |
$39K |
| D1120 |
Prophylaxis - child |
377 |
377 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
121 |
79 |
$12K |
| D1351 |
Sealant - per tooth |
333 |
116 |
$10K |
| D1206 |
Topical application of fluoride varnish |
387 |
387 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
179 |
179 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
193 |
193 |
$5K |
| D0274 |
Bitewings - four radiographic images |
118 |
118 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
139 |
139 |
$2K |
| D0272 |
Bitewings - two radiographic images |
76 |
76 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
143 |
131 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
13 |
12 |
$1K |