| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,928 |
1,918 |
$121K |
| D0210 |
Intraoral - complete series of radiographic images |
1,893 |
1,883 |
$89K |
| D0120 |
Periodic oral evaluation - established patient |
1,137 |
1,136 |
$62K |
| D1110 |
Prophylaxis - adult |
402 |
402 |
$35K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,928 |
1,087 |
$24K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
36 |
25 |
$17K |
| D0274 |
Bitewings - four radiographic images |
747 |
747 |
$16K |
| D1206 |
Topical application of fluoride varnish |
611 |
611 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
143 |
61 |
$10K |
| D1120 |
Prophylaxis - child |
217 |
216 |
$7K |
| D4910 |
|
90 |
81 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
314 |
311 |
$3K |
| D0350 |
|
211 |
75 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
36 |
36 |
$1K |
| D1999 |
|
763 |
593 |
$506.00 |