| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
328 |
200 |
$42K |
| D2740 |
Crown - porcelain/ceramic |
48 |
33 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
834 |
832 |
$22K |
| D1110 |
Prophylaxis - adult |
384 |
383 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
416 |
416 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
118 |
72 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
170 |
162 |
$12K |
| D1206 |
Topical application of fluoride varnish |
488 |
483 |
$11K |
| D1120 |
Prophylaxis - child |
246 |
246 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
501 |
471 |
$8K |
| D2950 |
|
32 |
19 |
$6K |
| D0274 |
Bitewings - four radiographic images |
79 |
79 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
249 |
219 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$400.00 |