| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
422 |
130 |
$24K |
| D1110 |
Prophylaxis - adult |
588 |
585 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
180 |
171 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
394 |
392 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
349 |
347 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
355 |
346 |
$2K |
| D0274 |
Bitewings - four radiographic images |
132 |
130 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
257 |
218 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$774.71 |
| D9994 |
|
237 |
237 |
$0.00 |
| D9630 |
|
12 |
12 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$0.00 |
| D2954 |
|
53 |
37 |
$0.00 |
| D2740 |
Crown - porcelain/ceramic |
50 |
33 |
$0.00 |