| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
240 |
88 |
$31K |
| D1120 |
Prophylaxis - child |
513 |
513 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
175 |
89 |
$17K |
| D1206 |
Topical application of fluoride varnish |
519 |
518 |
$11K |
| D1351 |
Sealant - per tooth |
358 |
117 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
208 |
208 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
262 |
262 |
$6K |
| D0272 |
Bitewings - two radiographic images |
163 |
163 |
$4K |
| D0274 |
Bitewings - four radiographic images |
82 |
82 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
154 |
154 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
153 |
142 |
$1K |