| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
741 |
740 |
$44K |
| D1120 |
Prophylaxis - child |
886 |
881 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
615 |
613 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
352 |
164 |
$23K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
49 |
38 |
$23K |
| D0210 |
Intraoral - complete series of radiographic images |
514 |
513 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,537 |
1,531 |
$18K |
| D1110 |
Prophylaxis - adult |
234 |
234 |
$15K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
222 |
107 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
234 |
126 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,264 |
676 |
$9K |
| D2140 |
|
122 |
64 |
$6K |
| D0274 |
Bitewings - four radiographic images |
241 |
240 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
114 |
114 |
$1K |
| D0272 |
Bitewings - two radiographic images |
64 |
64 |
$768.00 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$350.00 |
| D0350 |
|
12 |
12 |
$28.80 |
| D1999 |
|
16 |
16 |
$0.00 |
| D1330 |
|
55 |
55 |
$0.00 |