| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
152 |
55 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
195 |
188 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
98 |
33 |
$6K |
| D1351 |
Sealant - per tooth |
182 |
37 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
29 |
12 |
$3K |
| D0330 |
Panoramic radiographic image |
131 |
126 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
627 |
176 |
$3K |
| D0274 |
Bitewings - four radiographic images |
107 |
103 |
$2K |
| D1120 |
Prophylaxis - child |
58 |
56 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
117 |
115 |
$1K |
| D1110 |
Prophylaxis - adult |
30 |
29 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
182 |
176 |
$994.22 |
| D0603 |
|
204 |
199 |
$0.00 |