| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
144 |
44 |
$12K |
| D1110 |
Prophylaxis - adult |
294 |
294 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
264 |
254 |
$12K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
34 |
26 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
326 |
325 |
$8K |
| D1206 |
Topical application of fluoride varnish |
166 |
166 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
704 |
696 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
110 |
110 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
59 |
59 |
$3K |
| D0274 |
Bitewings - four radiographic images |
204 |
203 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
12 |
$2K |
| D1120 |
Prophylaxis - child |
24 |
24 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
277 |
277 |
$1K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$520.00 |
| D2950 |
|
15 |
12 |
$275.00 |