| Code | Description | Claims | Beneficiaries | Total Paid |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
861 |
560 |
$46K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
710 |
408 |
$36K |
| D1120 |
Prophylaxis - child |
1,563 |
1,555 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,744 |
1,736 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
903 |
897 |
$24K |
| D1351 |
Sealant - per tooth |
1,038 |
396 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
935 |
932 |
$16K |
| D0330 |
Panoramic radiographic image |
334 |
330 |
$15K |
| D0272 |
Bitewings - two radiographic images |
1,074 |
1,066 |
$11K |
| D1110 |
Prophylaxis - adult |
217 |
217 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
322 |
316 |
$7K |
| D0274 |
Bitewings - four radiographic images |
247 |
247 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
66 |
41 |
$4K |
| D2140 |
|
65 |
39 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
96 |
86 |
$2K |
| V2020 |
Frames, purchases |
155 |
153 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
296 |
293 |
$1K |
| V2100 |
Sphere, single vision, plano to plus or minus 4.00, per lens |
84 |
82 |
$1K |
| 92004 |
Ophthalmological services: medical examination and evaluation, comprehensive, new patient |
23 |
23 |
$650.00 |
| 92014 |
Ophthalmological services: medical examination and evaluation, comprehensive, established patient |
12 |
12 |
$450.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
18 |
16 |
$90.00 |
| V2784 |
Lens, polycarbonate or equal, any index, per lens |
16 |
16 |
$78.00 |
| 92015 |
Determination of refractive state |
64 |
62 |
$0.00 |