| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
327 |
192 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
942 |
940 |
$19K |
| D1110 |
Prophylaxis - adult |
332 |
332 |
$13K |
| D1206 |
Topical application of fluoride varnish |
732 |
730 |
$13K |
| D1120 |
Prophylaxis - child |
472 |
470 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
68 |
49 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
49 |
34 |
$3K |
| D0330 |
Panoramic radiographic image |
29 |
29 |
$3K |
| D0272 |
Bitewings - two radiographic images |
167 |
167 |
$2K |
| D1351 |
Sealant - per tooth |
45 |
14 |
$990.00 |
| D0220 |
Intraoral - periapical first radiographic image |
81 |
81 |
$680.31 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$280.00 |