| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,381 |
1,654 |
$141K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,610 |
1,245 |
$71K |
| D1110 |
Prophylaxis - adult |
2,287 |
2,278 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,211 |
2,206 |
$27K |
| D0272 |
Bitewings - two radiographic images |
2,679 |
2,670 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
3,338 |
3,244 |
$10K |
| D2332 |
|
204 |
78 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,837 |
2,824 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
144 |
107 |
$5K |
| D2330 |
|
160 |
84 |
$4K |
| D1120 |
Prophylaxis - child |
204 |
204 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
102 |
102 |
$791.00 |
| D0140 |
Limited oral evaluation - problem focused |
28 |
28 |
$274.00 |