| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
544 |
311 |
$41K |
| D1110 |
Prophylaxis - adult |
959 |
930 |
$40K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
573 |
310 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
716 |
690 |
$20K |
| D1206 |
Topical application of fluoride varnish |
951 |
917 |
$20K |
| D0274 |
Bitewings - four radiographic images |
805 |
780 |
$20K |
| D2740 |
Crown - porcelain/ceramic |
31 |
24 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,068 |
967 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,320 |
658 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
427 |
423 |
$10K |
| D0330 |
Panoramic radiographic image |
276 |
259 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
260 |
250 |
$5K |