| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
873 |
519 |
$96K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
587 |
381 |
$52K |
| D1120 |
Prophylaxis - child |
1,314 |
1,312 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
1,715 |
1,713 |
$44K |
| D1110 |
Prophylaxis - adult |
714 |
711 |
$34K |
| D1206 |
Topical application of fluoride varnish |
775 |
774 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
865 |
861 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
995 |
985 |
$15K |
| D0274 |
Bitewings - four radiographic images |
413 |
413 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
808 |
780 |
$7K |
| D0272 |
Bitewings - two radiographic images |
301 |
301 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
107 |
107 |
$4K |
| D0330 |
Panoramic radiographic image |
62 |
62 |
$3K |