| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
693 |
693 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
144 |
81 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
361 |
361 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
438 |
438 |
$12K |
| D2740 |
Crown - porcelain/ceramic |
16 |
14 |
$11K |
| D0274 |
Bitewings - four radiographic images |
414 |
414 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
441 |
386 |
$7K |
| D1206 |
Topical application of fluoride varnish |
347 |
347 |
$6K |
| D0330 |
Panoramic radiographic image |
71 |
71 |
$4K |
| D1120 |
Prophylaxis - child |
87 |
87 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
13 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
58 |
55 |
$3K |
| D2950 |
|
13 |
13 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
45 |
30 |
$328.85 |