| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,986 |
296 |
$183K |
| D0330 |
Panoramic radiographic image |
288 |
287 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
442 |
439 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
108 |
41 |
$11K |
| D1321 |
|
475 |
473 |
$10K |
| D1320 |
|
474 |
471 |
$10K |
| D1110 |
Prophylaxis - adult |
134 |
134 |
$7K |
| D2330 |
|
115 |
13 |
$6K |
| D0350 |
|
214 |
214 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
29 |
29 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
47 |
14 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
131 |
131 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
67 |
67 |
$2K |
| D1120 |
Prophylaxis - child |
30 |
30 |
$927.96 |
| D0274 |
Bitewings - four radiographic images |
17 |
17 |
$432.30 |
| D0220 |
Intraoral - periapical first radiographic image |
59 |
57 |
$352.96 |
| D1310 |
|
15 |
15 |
$0.00 |
| D1330 |
|
15 |
15 |
$0.00 |