| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
641 |
421 |
$73K |
| D1120 |
Prophylaxis - child |
697 |
697 |
$28K |
| D1110 |
Prophylaxis - adult |
422 |
422 |
$19K |
| D1351 |
Sealant - per tooth |
594 |
77 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
657 |
657 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
398 |
398 |
$16K |
| D1206 |
Topical application of fluoride varnish |
451 |
451 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
71 |
56 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
330 |
330 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
405 |
404 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
93 |
93 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
410 |
174 |
$4K |
| D0274 |
Bitewings - four radiographic images |
116 |
116 |
$3K |