| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
161 |
54 |
$14K |
| D1110 |
Prophylaxis - adult |
168 |
167 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
113 |
26 |
$8K |
| D2740 |
Crown - porcelain/ceramic |
49 |
28 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
159 |
152 |
$5K |
| D0274 |
Bitewings - four radiographic images |
119 |
119 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
148 |
147 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
90 |
90 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
47 |
32 |
$1K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$402.24 |
| D2950 |
|
15 |
12 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
26 |
$0.00 |