| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
556 |
248 |
$51K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
401 |
210 |
$30K |
| D1351 |
Sealant - per tooth |
911 |
205 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,464 |
508 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
456 |
439 |
$15K |
| D1120 |
Prophylaxis - child |
386 |
372 |
$13K |
| D1110 |
Prophylaxis - adult |
161 |
156 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
56 |
54 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
551 |
532 |
$8K |
| D0274 |
Bitewings - four radiographic images |
254 |
246 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
526 |
508 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
104 |
101 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
35 |
35 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
64 |
60 |
$1K |
| D0330 |
Panoramic radiographic image |
92 |
90 |
$833.09 |
| D0603 |
|
626 |
597 |
$0.00 |