| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
729 |
432 |
$94K |
| D2740 |
Crown - porcelain/ceramic |
39 |
28 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
847 |
847 |
$24K |
| D1110 |
Prophylaxis - adult |
431 |
431 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
219 |
147 |
$22K |
| D1120 |
Prophylaxis - child |
494 |
494 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
715 |
715 |
$18K |
| D0274 |
Bitewings - four radiographic images |
531 |
531 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
327 |
327 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
780 |
756 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
85 |
66 |
$13K |
| D0330 |
Panoramic radiographic image |
175 |
175 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
214 |
213 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
356 |
214 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
14 |
$705.00 |