| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,382 |
545 |
$262K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,381 |
380 |
$144K |
| D1110 |
Prophylaxis - adult |
859 |
845 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,472 |
1,451 |
$31K |
| D1206 |
Topical application of fluoride varnish |
1,859 |
1,823 |
$30K |
| D1120 |
Prophylaxis - child |
862 |
853 |
$26K |
| D0274 |
Bitewings - four radiographic images |
847 |
832 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
1,440 |
1,407 |
$22K |
| D1320 |
|
640 |
633 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,153 |
1,224 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
254 |
239 |
$8K |
| D0330 |
Panoramic radiographic image |
83 |
83 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
146 |
146 |
$2K |