| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,461 |
575 |
$111K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,053 |
506 |
$92K |
| D1110 |
Prophylaxis - adult |
1,684 |
1,682 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
2,013 |
2,009 |
$44K |
| D0210 |
Intraoral - complete series of radiographic images |
1,252 |
1,250 |
$36K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
394 |
241 |
$35K |
| D2954 |
|
167 |
121 |
$21K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
14 |
12 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
356 |
354 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
396 |
395 |
$3K |
| D2394 |
|
13 |
13 |
$1K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$513.00 |