| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
5,767 |
1,510 |
$289K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,251 |
1,318 |
$283K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,218 |
2,079 |
$79K |
| D1110 |
Prophylaxis - adult |
1,848 |
1,762 |
$74K |
| D0120 |
Periodic oral evaluation - established patient |
2,322 |
2,272 |
$60K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,355 |
3,238 |
$57K |
| D0140 |
Limited oral evaluation - problem focused |
1,710 |
1,585 |
$47K |
| D0220 |
Intraoral - periapical first radiographic image |
5,087 |
4,696 |
$46K |
| D0274 |
Bitewings - four radiographic images |
3,353 |
3,199 |
$43K |
| D4341 |
|
1,039 |
459 |
$39K |
| D1120 |
Prophylaxis - child |
782 |
766 |
$18K |
| D1351 |
Sealant - per tooth |
939 |
193 |
$18K |
| D1999 |
|
790 |
603 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,330 |
3,713 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
101 |
50 |
$8K |
| D4910 |
|
28 |
28 |
$1K |
| D2330 |
|
23 |
13 |
$788.64 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$333.50 |