| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,933 |
876 |
$105K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,068 |
537 |
$72K |
| D0120 |
Periodic oral evaluation - established patient |
1,054 |
1,054 |
$52K |
| D1120 |
Prophylaxis - child |
833 |
833 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,699 |
1,242 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,481 |
1,481 |
$17K |
| D0274 |
Bitewings - four radiographic images |
754 |
754 |
$16K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
193 |
114 |
$13K |
| D1110 |
Prophylaxis - adult |
135 |
135 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
120 |
120 |
$8K |
| D2160 |
|
68 |
38 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
97 |
97 |
$5K |
| D1351 |
Sealant - per tooth |
184 |
53 |
$4K |