| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,026 |
756 |
$200K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,116 |
1,114 |
$74K |
| D1110 |
Prophylaxis - adult |
741 |
735 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
773 |
771 |
$56K |
| D0210 |
Intraoral - complete series of radiographic images |
689 |
687 |
$32K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
60 |
45 |
$29K |
| D9430 |
|
783 |
771 |
$25K |
| D1120 |
Prophylaxis - child |
523 |
523 |
$22K |
| D0274 |
Bitewings - four radiographic images |
966 |
964 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,225 |
1,221 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,011 |
1,478 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
68 |
35 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
89 |
33 |
$4K |
| D2330 |
|
49 |
15 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
168 |
166 |
$2K |
| D4910 |
|
24 |
24 |
$2K |
| D0350 |
|
44 |
44 |
$403.20 |