| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
419 |
169 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
369 |
367 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
358 |
118 |
$20K |
| D9430 |
|
566 |
493 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
211 |
209 |
$10K |
| D2740 |
Crown - porcelain/ceramic |
19 |
12 |
$9K |
| D1110 |
Prophylaxis - adult |
103 |
103 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
321 |
319 |
$5K |
| D0350 |
|
170 |
56 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
383 |
110 |
$2K |
| D1120 |
Prophylaxis - child |
28 |
28 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
16 |
16 |
$995.00 |