| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
464 |
245 |
$45K |
| D0330 |
Panoramic radiographic image |
816 |
807 |
$44K |
| D1110 |
Prophylaxis - adult |
684 |
678 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
859 |
833 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
475 |
466 |
$21K |
| D1120 |
Prophylaxis - child |
660 |
637 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
943 |
919 |
$18K |
| D1351 |
Sealant - per tooth |
516 |
174 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
814 |
744 |
$10K |
| D0272 |
Bitewings - two radiographic images |
477 |
452 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
827 |
484 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
60 |
43 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
14 |
$1K |