| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,112 |
871 |
$157K |
| D1110 |
Prophylaxis - adult |
1,747 |
1,738 |
$97K |
| D0274 |
Bitewings - four radiographic images |
1,837 |
1,826 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
2,084 |
2,074 |
$53K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,175 |
1,173 |
$35K |
| D1120 |
Prophylaxis - child |
558 |
557 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
254 |
157 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
879 |
852 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
846 |
503 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
180 |
177 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
17 |
16 |
$504.80 |