| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
116 |
56 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
106 |
52 |
$10K |
| D1120 |
Prophylaxis - child |
105 |
105 |
$4K |
| D1351 |
Sealant - per tooth |
110 |
35 |
$3K |
| D1206 |
Topical application of fluoride varnish |
107 |
107 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
53 |
53 |
$2K |
| D0274 |
Bitewings - four radiographic images |
34 |
34 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
29 |
29 |
$784.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$204.00 |