| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
477 |
247 |
$65K |
| D1110 |
Prophylaxis - adult |
448 |
411 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
804 |
728 |
$20K |
| D1206 |
Topical application of fluoride varnish |
679 |
609 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
180 |
114 |
$14K |
| D1120 |
Prophylaxis - child |
383 |
342 |
$14K |
| D2740 |
Crown - porcelain/ceramic |
19 |
15 |
$13K |
| D0274 |
Bitewings - four radiographic images |
283 |
260 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
47 |
29 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
155 |
136 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
92 |
82 |
$3K |
| D0272 |
Bitewings - two radiographic images |
98 |
88 |
$2K |
| D4910 |
|
18 |
12 |
$811.80 |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
26 |
$485.90 |
| D9630 |
|
31 |
24 |
$405.90 |