| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
402 |
258 |
$48K |
| D2740 |
Crown - porcelain/ceramic |
79 |
56 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,309 |
1,309 |
$35K |
| D1110 |
Prophylaxis - adult |
686 |
686 |
$34K |
| D1120 |
Prophylaxis - child |
599 |
596 |
$25K |
| D0274 |
Bitewings - four radiographic images |
708 |
707 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,220 |
1,195 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
152 |
106 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,484 |
866 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
255 |
255 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
465 |
463 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
56 |
41 |
$8K |
| D2950 |
|
51 |
42 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
54 |
53 |
$2K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$1K |
| D1206 |
Topical application of fluoride varnish |
49 |
49 |
$1K |