| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,951 |
2,271 |
$166K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,309 |
1,696 |
$155K |
| D1110 |
Prophylaxis - adult |
4,507 |
4,493 |
$145K |
| D0120 |
Periodic oral evaluation - established patient |
5,561 |
5,545 |
$106K |
| D0274 |
Bitewings - four radiographic images |
4,428 |
4,421 |
$81K |
| D0220 |
Intraoral - periapical first radiographic image |
3,156 |
3,150 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,232 |
2,230 |
$10K |
| D1120 |
Prophylaxis - child |
252 |
252 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
583 |
570 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
476 |
476 |
$5K |
| D2330 |
|
118 |
67 |
$4K |