| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
159 |
81 |
$11K |
| D2740 |
Crown - porcelain/ceramic |
19 |
15 |
$10K |
| D1206 |
Topical application of fluoride varnish |
49 |
49 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
14 |
$1K |
| D1120 |
Prophylaxis - child |
28 |
28 |
$1K |
| D0274 |
Bitewings - four radiographic images |
47 |
47 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
30 |
30 |
$615.60 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$360.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$325.00 |