| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
455 |
213 |
$32K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
328 |
183 |
$25K |
| D2740 |
Crown - porcelain/ceramic |
41 |
37 |
$17K |
| D2332 |
|
216 |
98 |
$16K |
| D1110 |
Prophylaxis - adult |
217 |
216 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
144 |
143 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
212 |
211 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
301 |
300 |
$4K |
| D2950 |
|
42 |
37 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
89 |
89 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
14 |
$1K |
| D1120 |
Prophylaxis - child |
39 |
39 |
$1K |
| D0274 |
Bitewings - four radiographic images |
36 |
36 |
$745.74 |
| D0603 |
|
80 |
79 |
$373.50 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$321.16 |
| D0602 |
|
55 |
55 |
$251.25 |
| D0601 |
|
26 |
26 |
$103.00 |