| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
46 |
25 |
$4K |
| D1351 |
Sealant - per tooth |
121 |
38 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
70 |
70 |
$3K |
| D1120 |
Prophylaxis - child |
86 |
84 |
$3K |
| D0272 |
Bitewings - two radiographic images |
79 |
79 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
30 |
19 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
42 |
40 |
$587.60 |
| D0120 |
Periodic oral evaluation - established patient |
21 |
21 |
$572.04 |
| D1208 |
Topical application of fluoride, excluding varnish |
35 |
34 |
$533.79 |
| D1206 |
Topical application of fluoride varnish |
23 |
22 |
$485.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
36 |
35 |
$447.12 |