| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
241 |
67 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
166 |
49 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
186 |
61 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
244 |
235 |
$6K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
92 |
30 |
$5K |
| D0274 |
Bitewings - four radiographic images |
214 |
210 |
$4K |
| D2160 |
|
62 |
28 |
$4K |
| D2140 |
|
96 |
25 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
723 |
268 |
$3K |
| D1110 |
Prophylaxis - adult |
84 |
82 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
402 |
348 |
$2K |
| D0330 |
Panoramic radiographic image |
13 |
12 |
$602.16 |