| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
444 |
228 |
$52K |
| D1120 |
Prophylaxis - child |
1,114 |
1,105 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,355 |
1,345 |
$35K |
| D1206 |
Topical application of fluoride varnish |
1,183 |
1,174 |
$28K |
| D1351 |
Sealant - per tooth |
698 |
91 |
$21K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
63 |
39 |
$9K |
| D1110 |
Prophylaxis - adult |
197 |
195 |
$9K |
| D0274 |
Bitewings - four radiographic images |
156 |
155 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
25 |
$4K |
| D0272 |
Bitewings - two radiographic images |
159 |
158 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
207 |
196 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
59 |
58 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
87 |
56 |
$900.00 |
| D1999 |
|
196 |
152 |
$0.00 |