| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
481 |
223 |
$36K |
| D1110 |
Prophylaxis - adult |
765 |
757 |
$25K |
| D2740 |
Crown - porcelain/ceramic |
156 |
90 |
$10K |
| D0274 |
Bitewings - four radiographic images |
587 |
576 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
436 |
430 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
102 |
50 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
747 |
693 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
362 |
190 |
$5K |
| D2950 |
|
169 |
114 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
397 |
395 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
228 |
220 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
140 |
135 |
$1K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$921.90 |