| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
310 |
154 |
$45K |
| D1110 |
Prophylaxis - adult |
547 |
478 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
489 |
431 |
$20K |
| D1206 |
Topical application of fluoride varnish |
778 |
704 |
$20K |
| D2740 |
Crown - porcelain/ceramic |
29 |
24 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
259 |
224 |
$14K |
| D0274 |
Bitewings - four radiographic images |
215 |
190 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
145 |
138 |
$9K |
| D0330 |
Panoramic radiographic image |
82 |
71 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
39 |
27 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
182 |
144 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
160 |
148 |
$4K |
| D1120 |
Prophylaxis - child |
56 |
54 |
$4K |