| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
372 |
210 |
$46K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
254 |
126 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
613 |
610 |
$17K |
| D1120 |
Prophylaxis - child |
332 |
331 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
361 |
348 |
$14K |
| D1110 |
Prophylaxis - adult |
280 |
278 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
892 |
793 |
$13K |
| D0330 |
Panoramic radiographic image |
224 |
224 |
$11K |
| D1206 |
Topical application of fluoride varnish |
344 |
342 |
$10K |
| D2740 |
Crown - porcelain/ceramic |
17 |
12 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,091 |
589 |
$9K |
| D2950 |
|
51 |
41 |
$8K |
| D0274 |
Bitewings - four radiographic images |
248 |
247 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
14 |
$1K |