| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
304 |
108 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
91 |
53 |
$7K |
| D1120 |
Prophylaxis - child |
196 |
196 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
74 |
74 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
283 |
283 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
94 |
94 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
375 |
371 |
$3K |
| D0272 |
Bitewings - two radiographic images |
185 |
185 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
346 |
343 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
61 |
61 |
$2K |
| D1351 |
Sealant - per tooth |
63 |
19 |
$1K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$138.44 |
| D0330 |
Panoramic radiographic image |
76 |
76 |
$127.56 |
| D0603 |
|
349 |
347 |
$0.00 |