| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
542 |
542 |
$36K |
| D0350 |
|
3,500 |
775 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
397 |
397 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
375 |
232 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
416 |
416 |
$19K |
| D1110 |
Prophylaxis - adult |
145 |
145 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
636 |
636 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
160 |
79 |
$9K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
16 |
13 |
$8K |
| D1120 |
Prophylaxis - child |
138 |
138 |
$7K |
| D0274 |
Bitewings - four radiographic images |
328 |
328 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
994 |
563 |
$4K |
| D9430 |
|
27 |
27 |
$864.00 |
| D0220 |
Intraoral - periapical first radiographic image |
55 |
54 |
$660.00 |
| D1999 |
|
202 |
163 |
$0.00 |