| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
421 |
185 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
582 |
575 |
$16K |
| D1110 |
Prophylaxis - adult |
729 |
722 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
288 |
98 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
350 |
350 |
$10K |
| D2332 |
|
161 |
74 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
249 |
247 |
$6K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
14 |
13 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
82 |
38 |
$3K |
| D0330 |
Panoramic radiographic image |
538 |
533 |
$3K |
| D0274 |
Bitewings - four radiographic images |
618 |
614 |
$2K |
| D2330 |
|
34 |
13 |
$1K |
| D2394 |
|
19 |
14 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
635 |
627 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
47 |
47 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
626 |
621 |
$747.00 |