| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
740 |
735 |
$49K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
382 |
137 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,981 |
933 |
$21K |
| D0350 |
|
1,924 |
555 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
171 |
86 |
$11K |
| D0274 |
Bitewings - four radiographic images |
510 |
503 |
$11K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
20 |
13 |
$10K |
| D1110 |
Prophylaxis - adult |
101 |
101 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
396 |
392 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
65 |
65 |
$5K |
| D1120 |
Prophylaxis - child |
82 |
82 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
33 |
13 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
31 |
31 |
$1K |
| D9430 |
|
37 |
37 |
$1K |
| D0272 |
Bitewings - two radiographic images |
37 |
37 |
$444.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$144.00 |