| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
462 |
234 |
$51K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
468 |
219 |
$32K |
| D1110 |
Prophylaxis - adult |
627 |
624 |
$21K |
| D9110 |
|
111 |
107 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
244 |
237 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
204 |
197 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
406 |
403 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
546 |
484 |
$4K |
| D0274 |
Bitewings - four radiographic images |
282 |
280 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
18 |
18 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
47 |
26 |
$682.91 |
| D9994 |
|
85 |
85 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
86 |
38 |
$0.00 |
| D2740 |
Crown - porcelain/ceramic |
15 |
13 |
$0.00 |
| D2950 |
|
15 |
12 |
$0.00 |