| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
193 |
109 |
$26K |
| D1110 |
Prophylaxis - adult |
389 |
379 |
$19K |
| D2740 |
Crown - porcelain/ceramic |
34 |
30 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
293 |
285 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
176 |
174 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
458 |
428 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
187 |
176 |
$3K |
| D0274 |
Bitewings - four radiographic images |
97 |
93 |
$3K |
| D0460 |
|
105 |
99 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
14 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
41 |
41 |
$2K |
| D2950 |
|
18 |
15 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
61 |
61 |
$2K |
| D0350 |
|
32 |
28 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$602.36 |