| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
174 |
82 |
$13K |
| D2740 |
Crown - porcelain/ceramic |
19 |
13 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
270 |
258 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
177 |
171 |
$8K |
| D1110 |
Prophylaxis - adult |
145 |
142 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
362 |
313 |
$2K |
| D2950 |
|
14 |
12 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
37 |
36 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
58 |
54 |
$901.00 |
| D0274 |
Bitewings - four radiographic images |
45 |
44 |
$740.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
139 |
89 |
$480.00 |
| D0350 |
|
12 |
12 |
$12.00 |