| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
654 |
654 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
619 |
255 |
$42K |
| D2740 |
Crown - porcelain/ceramic |
73 |
56 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
304 |
304 |
$23K |
| D0210 |
Intraoral - complete series of radiographic images |
439 |
439 |
$21K |
| D1110 |
Prophylaxis - adult |
212 |
211 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,961 |
899 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
189 |
89 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
829 |
824 |
$11K |
| D0350 |
|
943 |
276 |
$9K |
| D1120 |
Prophylaxis - child |
185 |
185 |
$6K |
| D0272 |
Bitewings - two radiographic images |
360 |
360 |
$4K |
| D9430 |
|
110 |
110 |
$4K |
| D2954 |
|
30 |
25 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
45 |
14 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
54 |
25 |
$3K |
| D0274 |
Bitewings - four radiographic images |
81 |
81 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
70 |
66 |
$840.00 |