| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
66 |
13 |
$6K |
| D1110 |
Prophylaxis - adult |
177 |
174 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
469 |
400 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
277 |
275 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
26 |
$926.74 |
| D0230 |
Intraoral - periapical each additional radiographic image |
216 |
162 |
$726.50 |
| D0274 |
Bitewings - four radiographic images |
56 |
56 |
$502.32 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$435.76 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$435.01 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$332.64 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$249.48 |
| D9630 |
|
186 |
186 |
$0.00 |
| D2950 |
|
51 |
24 |
$0.00 |
| D2740 |
Crown - porcelain/ceramic |
56 |
25 |
$0.00 |