| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
322 |
189 |
$52K |
| D1110 |
Prophylaxis - adult |
406 |
390 |
$33K |
| D2740 |
Crown - porcelain/ceramic |
37 |
27 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
436 |
426 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
220 |
213 |
$13K |
| D0274 |
Bitewings - four radiographic images |
179 |
175 |
$10K |
| D2950 |
|
52 |
45 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
136 |
134 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
25 |
$5K |
| D0330 |
Panoramic radiographic image |
38 |
36 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
131 |
128 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$1K |
| D4910 |
|
12 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
28 |
26 |
$684.00 |