| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
536 |
534 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
316 |
168 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
329 |
326 |
$15K |
| D2740 |
Crown - porcelain/ceramic |
15 |
13 |
$7K |
| D0350 |
|
797 |
264 |
$7K |
| D1206 |
Topical application of fluoride varnish |
199 |
198 |
$3K |
| D1120 |
Prophylaxis - child |
46 |
46 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
29 |
29 |
$2K |
| D0330 |
Panoramic radiographic image |
35 |
35 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
388 |
80 |
$826.20 |
| D1310 |
|
51 |
50 |
$46.00 |
| D0602 |
|
29 |
29 |
$0.00 |