| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
113 |
39 |
$11K |
| D2332 |
|
74 |
25 |
$11K |
| D2335 |
|
33 |
13 |
$6K |
| D0330 |
Panoramic radiographic image |
47 |
47 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
57 |
57 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
14 |
$2K |
| D1110 |
Prophylaxis - adult |
26 |
26 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
34 |
28 |
$383.37 |
| D0220 |
Intraoral - periapical first radiographic image |
37 |
36 |
$363.71 |