| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
226 |
116 |
$24K |
| D1120 |
Prophylaxis - child |
693 |
693 |
$24K |
| D2740 |
Crown - porcelain/ceramic |
41 |
24 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
486 |
486 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
366 |
366 |
$16K |
| D1206 |
Topical application of fluoride varnish |
744 |
744 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
561 |
561 |
$13K |
| D1110 |
Prophylaxis - adult |
256 |
256 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
555 |
551 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
448 |
443 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
79 |
79 |
$3K |
| D0274 |
Bitewings - four radiographic images |
89 |
89 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
15 |
$2K |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$450.00 |