| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,992 |
701 |
$247K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,467 |
797 |
$235K |
| D1110 |
Prophylaxis - adult |
2,513 |
1,815 |
$81K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,403 |
2,398 |
$49K |
| D9630 |
|
2,497 |
2,482 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
2,740 |
2,407 |
$46K |
| D1120 |
Prophylaxis - child |
1,248 |
1,248 |
$41K |
| D0272 |
Bitewings - two radiographic images |
2,228 |
1,779 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,823 |
991 |
$30K |
| D0330 |
Panoramic radiographic image |
1,339 |
580 |
$29K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
250 |
153 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
479 |
459 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
79 |
38 |
$943.54 |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
12 |
$134.16 |