| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
774 |
360 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
578 |
575 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
95 |
67 |
$6K |
| D0274 |
Bitewings - four radiographic images |
290 |
290 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,316 |
559 |
$6K |
| D4341 |
|
83 |
26 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
83 |
83 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
66 |
66 |
$3K |
| D1120 |
Prophylaxis - child |
85 |
85 |
$3K |