| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,240 |
529 |
$110K |
| D9630 |
|
2,235 |
2,057 |
$44K |
| D1120 |
Prophylaxis - child |
1,300 |
1,300 |
$44K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,809 |
1,809 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
1,612 |
1,612 |
$32K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
381 |
232 |
$28K |
| D1110 |
Prophylaxis - adult |
460 |
460 |
$22K |
| D0272 |
Bitewings - two radiographic images |
670 |
670 |
$14K |
| D0330 |
Panoramic radiographic image |
165 |
165 |
$9K |
| D0274 |
Bitewings - four radiographic images |
212 |
212 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
136 |
136 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
35 |
30 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
115 |
113 |
$3K |
| D9920 |
|
39 |
39 |
$3K |
| D2394 |
|
18 |
14 |
$2K |
| D1351 |
Sealant - per tooth |
31 |
12 |
$1K |
| D1354 |
|
60 |
32 |
$720.00 |
| D0240 |
|
41 |
21 |
$503.07 |