| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
156 |
31 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
38 |
16 |
$4K |
| D1351 |
Sealant - per tooth |
84 |
18 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
65 |
65 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
61 |
61 |
$933.00 |
| D1120 |
Prophylaxis - child |
26 |
26 |
$747.45 |
| D0220 |
Intraoral - periapical first radiographic image |
62 |
62 |
$671.52 |
| D0230 |
Intraoral - periapical each additional radiographic image |
60 |
59 |
$638.52 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$329.94 |
| D0603 |
|
30 |
30 |
$0.00 |