| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
628 |
248 |
$28K |
| D1110 |
Prophylaxis - adult |
872 |
870 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
1,071 |
1,069 |
$13K |
| D0274 |
Bitewings - four radiographic images |
579 |
577 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
182 |
88 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
114 |
58 |
$9K |
| D1206 |
Topical application of fluoride varnish |
433 |
433 |
$5K |
| D1120 |
Prophylaxis - child |
164 |
164 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
160 |
159 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
128 |
125 |
$1K |
| D4910 |
|
39 |
38 |
$968.64 |
| D0330 |
Panoramic radiographic image |
60 |
60 |
$842.28 |
| D0140 |
Limited oral evaluation - problem focused |
63 |
60 |
$839.28 |
| D9630 |
|
27 |
26 |
$0.00 |
| D2950 |
|
132 |
84 |
$0.00 |
| D2740 |
Crown - porcelain/ceramic |
101 |
55 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$0.00 |