| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,486 |
810 |
$103K |
| D1110 |
Prophylaxis - adult |
1,329 |
1,328 |
$60K |
| D1206 |
Topical application of fluoride varnish |
1,508 |
1,507 |
$47K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
810 |
498 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,495 |
1,495 |
$37K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
200 |
148 |
$17K |
| D1120 |
Prophylaxis - child |
361 |
361 |
$16K |
| D0274 |
Bitewings - four radiographic images |
1,139 |
1,139 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
215 |
214 |
$10K |
| D1351 |
Sealant - per tooth |
426 |
94 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,422 |
1,421 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,524 |
1,523 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
256 |
255 |
$6K |
| D0603 |
|
473 |
473 |
$5K |
| D1353 |
|
177 |
31 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$540.00 |
| D0272 |
Bitewings - two radiographic images |
36 |
36 |
$360.00 |