| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,633 |
698 |
$198K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,304 |
529 |
$128K |
| D1110 |
Prophylaxis - adult |
931 |
912 |
$55K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,395 |
2,358 |
$55K |
| D1120 |
Prophylaxis - child |
1,219 |
1,203 |
$53K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,035 |
1,014 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
1,587 |
1,562 |
$46K |
| D0274 |
Bitewings - four radiographic images |
1,066 |
1,043 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
2,333 |
2,277 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,188 |
2,027 |
$19K |
| D1351 |
Sealant - per tooth |
366 |
63 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
23 |
14 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
76 |
76 |
$4K |
| D0272 |
Bitewings - two radiographic images |
182 |
180 |
$3K |
| D1330 |
|
387 |
374 |
$2K |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$1K |