| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
637 |
637 |
$42K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
68 |
46 |
$32K |
| D1120 |
Prophylaxis - child |
423 |
423 |
$22K |
| D1110 |
Prophylaxis - adult |
178 |
178 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
256 |
96 |
$14K |
| D1206 |
Topical application of fluoride varnish |
657 |
657 |
$11K |
| D1351 |
Sealant - per tooth |
254 |
66 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
174 |
174 |
$8K |
| D0274 |
Bitewings - four radiographic images |
344 |
344 |
$7K |
| D9430 |
|
225 |
218 |
$7K |
| D0350 |
|
743 |
248 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,562 |
567 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
115 |
114 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
68 |
30 |
$5K |
| D2954 |
|
19 |
13 |
$2K |
| D0272 |
Bitewings - two radiographic images |
102 |
102 |
$1K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$420.00 |