| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
732 |
341 |
$90K |
| D1120 |
Prophylaxis - child |
1,335 |
1,334 |
$50K |
| D1351 |
Sealant - per tooth |
1,426 |
228 |
$44K |
| D1206 |
Topical application of fluoride varnish |
1,658 |
1,658 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,434 |
1,433 |
$37K |
| D1110 |
Prophylaxis - adult |
451 |
451 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,245 |
1,109 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
202 |
108 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,261 |
1,249 |
$20K |
| D0274 |
Bitewings - four radiographic images |
530 |
530 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
266 |
266 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
27 |
14 |
$4K |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$1K |
| D0272 |
Bitewings - two radiographic images |
39 |
39 |
$847.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$574.74 |