| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,709 |
869 |
$225K |
| D1110 |
Prophylaxis - adult |
3,495 |
3,439 |
$224K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,497 |
6,390 |
$151K |
| D0120 |
Periodic oral evaluation - established patient |
3,661 |
3,618 |
$112K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,995 |
1,946 |
$108K |
| D1120 |
Prophylaxis - child |
1,948 |
1,914 |
$85K |
| D0210 |
Intraoral - complete series of radiographic images |
1,251 |
1,213 |
$69K |
| D0274 |
Bitewings - four radiographic images |
2,338 |
2,316 |
$55K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
298 |
186 |
$51K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
291 |
164 |
$30K |
| D1351 |
Sealant - per tooth |
629 |
159 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,808 |
1,773 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,187 |
1,183 |
$13K |
| D1330 |
|
1,601 |
1,570 |
$10K |
| D0330 |
Panoramic radiographic image |
230 |
222 |
$10K |
| D0272 |
Bitewings - two radiographic images |
654 |
640 |
$10K |
| D2740 |
Crown - porcelain/ceramic |
23 |
12 |
$9K |
| D3120 |
|
241 |
147 |
$8K |
| D2950 |
|
22 |
12 |
$2K |