| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
538 |
306 |
$71K |
| D1110 |
Prophylaxis - adult |
1,001 |
995 |
$66K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
580 |
263 |
$60K |
| D0140 |
Limited oral evaluation - problem focused |
1,221 |
1,030 |
$55K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,280 |
2,265 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
1,399 |
1,394 |
$42K |
| D1120 |
Prophylaxis - child |
691 |
686 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
540 |
534 |
$30K |
| D0330 |
Panoramic radiographic image |
532 |
527 |
$24K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
146 |
97 |
$23K |
| D0274 |
Bitewings - four radiographic images |
972 |
967 |
$23K |
| D1351 |
Sealant - per tooth |
461 |
112 |
$17K |
| D2335 |
|
61 |
29 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
63 |
29 |
$9K |
| D0272 |
Bitewings - two radiographic images |
268 |
264 |
$4K |
| D1330 |
|
457 |
456 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
158 |
143 |
$2K |