| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
130 |
97 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
144 |
98 |
$8K |
| D1351 |
Sealant - per tooth |
380 |
90 |
$8K |
| D0274 |
Bitewings - four radiographic images |
236 |
206 |
$6K |
| D1206 |
Topical application of fluoride varnish |
112 |
95 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
178 |
167 |
$4K |
| D1120 |
Prophylaxis - child |
92 |
77 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
34 |
34 |
$1K |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$468.00 |