| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
451 |
226 |
$99K |
| D1110 |
Prophylaxis - adult |
698 |
634 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
740 |
666 |
$32K |
| D1206 |
Topical application of fluoride varnish |
1,116 |
1,019 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
766 |
689 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
135 |
62 |
$25K |
| D0274 |
Bitewings - four radiographic images |
321 |
287 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
696 |
626 |
$15K |
| D1120 |
Prophylaxis - child |
285 |
263 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
289 |
263 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
564 |
459 |
$9K |
| D1351 |
Sealant - per tooth |
266 |
39 |
$8K |
| D0330 |
Panoramic radiographic image |
13 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
27 |
24 |
$880.23 |
| D0603 |
|
240 |
223 |
$0.00 |
| D0602 |
|
116 |
101 |
$0.00 |
| D0601 |
|
19 |
14 |
$0.00 |