| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
370 |
166 |
$17K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
31 |
25 |
$15K |
| D1110 |
Prophylaxis - adult |
587 |
562 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
462 |
442 |
$10K |
| D2740 |
Crown - porcelain/ceramic |
31 |
17 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
191 |
93 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
291 |
269 |
$6K |
| D0274 |
Bitewings - four radiographic images |
387 |
373 |
$5K |
| D0330 |
Panoramic radiographic image |
189 |
177 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
100 |
94 |
$4K |
| D2954 |
|
46 |
29 |
$3K |
| D1120 |
Prophylaxis - child |
105 |
99 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
697 |
630 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
107 |
100 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
672 |
503 |
$2K |
| D1206 |
Topical application of fluoride varnish |
57 |
56 |
$975.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
73 |
70 |
$842.00 |