| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
721 |
375 |
$48K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
96 |
58 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
703 |
701 |
$45K |
| D1110 |
Prophylaxis - adult |
404 |
404 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
465 |
465 |
$34K |
| D0210 |
Intraoral - complete series of radiographic images |
500 |
500 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
978 |
978 |
$13K |
| D1120 |
Prophylaxis - child |
224 |
224 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
155 |
83 |
$8K |
| D0274 |
Bitewings - four radiographic images |
300 |
300 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
71 |
48 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,370 |
688 |
$6K |
| D2954 |
|
35 |
25 |
$4K |
| D4910 |
|
41 |
41 |
$3K |
| D1206 |
Topical application of fluoride varnish |
51 |
51 |
$826.00 |