| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
724 |
390 |
$70K |
| D1351 |
Sealant - per tooth |
2,500 |
540 |
$64K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
744 |
385 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
1,326 |
1,311 |
$38K |
| D0145 |
Oral evaluation for a patient under three years of age |
226 |
226 |
$32K |
| D1120 |
Prophylaxis - child |
879 |
872 |
$31K |
| D1110 |
Prophylaxis - adult |
514 |
502 |
$27K |
| D0274 |
Bitewings - four radiographic images |
531 |
517 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,210 |
1,193 |
$17K |
| D0272 |
Bitewings - two radiographic images |
662 |
657 |
$15K |
| D1330 |
|
1,116 |
1,081 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
344 |
326 |
$4K |
| D0240 |
|
200 |
102 |
$2K |
| D1206 |
Topical application of fluoride varnish |
56 |
55 |
$808.50 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
16 |
$300.48 |
| D0602 |
|
237 |
235 |
$0.00 |
| D0603 |
|
775 |
770 |
$0.00 |
| D0601 |
|
594 |
591 |
$0.00 |