| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
138 |
104 |
$10K |
| D0274 |
Bitewings - four radiographic images |
209 |
205 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
221 |
220 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
66 |
53 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
106 |
103 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
13 |
13 |
$1K |
| D1351 |
Sealant - per tooth |
54 |
29 |
$1K |
| D0272 |
Bitewings - two radiographic images |
43 |
42 |
$756.00 |