| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
569 |
332 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
579 |
577 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
522 |
521 |
$36K |
| D1110 |
Prophylaxis - adult |
349 |
349 |
$30K |
| D0210 |
Intraoral - complete series of radiographic images |
415 |
415 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
357 |
186 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,186 |
866 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,057 |
1,055 |
$15K |
| D1120 |
Prophylaxis - child |
287 |
287 |
$13K |
| D0350 |
|
1,074 |
436 |
$10K |
| D0274 |
Bitewings - four radiographic images |
395 |
395 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
84 |
59 |
$7K |
| D2740 |
Crown - porcelain/ceramic |
14 |
12 |
$7K |
| D4910 |
|
73 |
73 |
$5K |
| D9430 |
|
50 |
46 |
$2K |
| D9994 |
|
12 |
12 |
$319.92 |
| D0270 |
|
28 |
25 |
$140.00 |