| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,143 |
551 |
$114K |
| D1110 |
Prophylaxis - adult |
2,899 |
2,433 |
$109K |
| D0120 |
Periodic oral evaluation - established patient |
3,785 |
3,155 |
$70K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,037 |
478 |
$59K |
| D0274 |
Bitewings - four radiographic images |
2,369 |
1,988 |
$50K |
| D0210 |
Intraoral - complete series of radiographic images |
589 |
412 |
$40K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,212 |
1,735 |
$35K |
| D1120 |
Prophylaxis - child |
1,616 |
1,239 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
682 |
477 |
$20K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
274 |
133 |
$17K |
| D2140 |
|
371 |
136 |
$15K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
197 |
116 |
$11K |
| D2335 |
|
95 |
43 |
$9K |
| D0272 |
Bitewings - two radiographic images |
805 |
626 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
199 |
145 |
$4K |
| D2332 |
|
30 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
252 |
217 |
$1K |
| D2160 |
|
18 |
13 |
$1K |
| D1206 |
Topical application of fluoride varnish |
36 |
36 |
$857.52 |