| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,405 |
511 |
$141K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
510 |
204 |
$28K |
| D1110 |
Prophylaxis - adult |
622 |
622 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
451 |
451 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
284 |
284 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
234 |
234 |
$7K |
| D0274 |
Bitewings - four radiographic images |
227 |
227 |
$5K |
| D0330 |
Panoramic radiographic image |
158 |
158 |
$5K |
| D2330 |
|
28 |
13 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
45 |
45 |
$923.86 |
| D1120 |
Prophylaxis - child |
24 |
24 |
$879.24 |
| D0220 |
Intraoral - periapical first radiographic image |
71 |
71 |
$604.22 |
| D1208 |
Topical application of fluoride, excluding varnish |
44 |
44 |
$551.24 |