| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
539 |
539 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
488 |
298 |
$32K |
| D2740 |
Crown - porcelain/ceramic |
60 |
48 |
$29K |
| D1110 |
Prophylaxis - adult |
300 |
300 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
463 |
463 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
188 |
131 |
$10K |
| D1206 |
Topical application of fluoride varnish |
434 |
434 |
$7K |
| D9430 |
|
206 |
183 |
$7K |
| D0350 |
|
545 |
256 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
39 |
28 |
$3K |
| D1120 |
Prophylaxis - child |
61 |
61 |
$3K |
| D2954 |
|
17 |
13 |
$2K |
| D1351 |
Sealant - per tooth |
41 |
12 |
$2K |
| D1320 |
|
26 |
26 |
$451.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
88 |
27 |
$356.40 |