| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
667 |
339 |
$87K |
| D1110 |
Prophylaxis - adult |
1,369 |
1,369 |
$74K |
| D0120 |
Periodic oral evaluation - established patient |
2,232 |
2,230 |
$63K |
| D1120 |
Prophylaxis - child |
1,109 |
1,109 |
$47K |
| D1206 |
Topical application of fluoride varnish |
1,695 |
1,694 |
$45K |
| D1351 |
Sealant - per tooth |
768 |
150 |
$25K |
| D0272 |
Bitewings - two radiographic images |
716 |
715 |
$17K |
| D0274 |
Bitewings - four radiographic images |
167 |
167 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
60 |
41 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
30 |
30 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
17 |
17 |
$811.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$753.59 |