| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
272 |
150 |
$15K |
| D2740 |
Crown - porcelain/ceramic |
28 |
25 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
149 |
96 |
$10K |
| D0330 |
Panoramic radiographic image |
132 |
129 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
130 |
119 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
152 |
143 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
93 |
59 |
$5K |
| D0274 |
Bitewings - four radiographic images |
149 |
142 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
273 |
235 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
39 |
28 |
$266.25 |