| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
518 |
223 |
$35K |
| D4910 |
|
344 |
341 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
334 |
333 |
$25K |
| D0350 |
|
2,263 |
522 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
317 |
317 |
$21K |
| D1110 |
Prophylaxis - adult |
161 |
161 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
881 |
880 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
213 |
213 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
174 |
83 |
$9K |
| D2740 |
Crown - porcelain/ceramic |
17 |
12 |
$8K |
| D9430 |
|
229 |
192 |
$7K |
| D1120 |
Prophylaxis - child |
96 |
96 |
$4K |
| D0274 |
Bitewings - four radiographic images |
131 |
131 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
28 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
451 |
223 |
$2K |
| D2954 |
|
14 |
13 |
$1K |
| D1320 |
|
14 |
14 |
$245.00 |
| D1999 |
|
35 |
28 |
$30.00 |