| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
430 |
97 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
295 |
85 |
$28K |
| D0210 |
Intraoral - complete series of radiographic images |
260 |
254 |
$18K |
| D1351 |
Sealant - per tooth |
513 |
143 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
319 |
310 |
$11K |
| D1120 |
Prophylaxis - child |
269 |
259 |
$10K |
| D1110 |
Prophylaxis - adult |
114 |
108 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
395 |
379 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
386 |
129 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
16 |
16 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
86 |
77 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
142 |
130 |
$2K |
| D0274 |
Bitewings - four radiographic images |
38 |
33 |
$1K |
| D0272 |
Bitewings - two radiographic images |
41 |
39 |
$911.82 |
| D0603 |
|
462 |
437 |
$0.00 |