| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
624 |
624 |
$41K |
| D2740 |
Crown - porcelain/ceramic |
61 |
44 |
$29K |
| D1110 |
Prophylaxis - adult |
324 |
324 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,436 |
1,200 |
$22K |
| D0274 |
Bitewings - four radiographic images |
685 |
679 |
$14K |
| D9430 |
|
155 |
153 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
69 |
69 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
76 |
37 |
$4K |
| D0330 |
Panoramic radiographic image |
121 |
121 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
27 |
$1K |
| D1120 |
Prophylaxis - child |
28 |
28 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$245.00 |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$180.00 |