| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,796 |
1,096 |
$171K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,212 |
644 |
$86K |
| D1110 |
Prophylaxis - adult |
2,085 |
2,005 |
$75K |
| D0210 |
Intraoral - complete series of radiographic images |
1,173 |
1,118 |
$71K |
| D0120 |
Periodic oral evaluation - established patient |
2,208 |
2,162 |
$54K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,922 |
1,896 |
$41K |
| D1120 |
Prophylaxis - child |
883 |
862 |
$38K |
| D0140 |
Limited oral evaluation - problem focused |
1,332 |
1,229 |
$37K |
| D0274 |
Bitewings - four radiographic images |
1,155 |
1,123 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
701 |
648 |
$29K |
| D2330 |
|
422 |
197 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
851 |
795 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
85 |
63 |
$8K |
| D2331 |
|
30 |
12 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
21 |
13 |
$231.15 |