| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
700 |
693 |
$46K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
416 |
190 |
$28K |
| D0210 |
Intraoral - complete series of radiographic images |
596 |
594 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
307 |
307 |
$17K |
| D2740 |
Crown - porcelain/ceramic |
30 |
18 |
$14K |
| D1110 |
Prophylaxis - adult |
154 |
153 |
$13K |
| D1206 |
Topical application of fluoride varnish |
591 |
583 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,235 |
402 |
$9K |
| D1120 |
Prophylaxis - child |
157 |
155 |
$8K |
| D0274 |
Bitewings - four radiographic images |
300 |
300 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
59 |
30 |
$3K |
| D0350 |
|
363 |
143 |
$3K |
| D4910 |
|
41 |
41 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$135.00 |