| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,090 |
1,248 |
$132K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,615 |
1,063 |
$125K |
| D1120 |
Prophylaxis - child |
3,302 |
3,220 |
$87K |
| D0120 |
Periodic oral evaluation - established patient |
4,891 |
4,755 |
$87K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,476 |
5,319 |
$74K |
| D1110 |
Prophylaxis - adult |
1,987 |
1,924 |
$65K |
| D0330 |
Panoramic radiographic image |
703 |
691 |
$31K |
| D0272 |
Bitewings - two radiographic images |
1,213 |
1,182 |
$21K |
| D0274 |
Bitewings - four radiographic images |
624 |
604 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,240 |
1,165 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
195 |
190 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
665 |
345 |
$4K |
| D1351 |
Sealant - per tooth |
130 |
38 |
$3K |
| D2330 |
|
20 |
13 |
$1K |