| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
762 |
759 |
$46K |
| D4910 |
|
367 |
366 |
$28K |
| D0210 |
Intraoral - complete series of radiographic images |
547 |
547 |
$24K |
| D9430 |
|
736 |
616 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
395 |
163 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
339 |
337 |
$21K |
| D1120 |
Prophylaxis - child |
380 |
377 |
$13K |
| D4341 |
|
157 |
43 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,451 |
864 |
$10K |
| D0350 |
|
920 |
308 |
$8K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
16 |
14 |
$8K |
| D0274 |
Bitewings - four radiographic images |
229 |
228 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
363 |
362 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
50 |
25 |
$3K |
| D2954 |
|
13 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
115 |
115 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
92 |
90 |
$1K |
| D0272 |
Bitewings - two radiographic images |
79 |
78 |
$936.00 |