| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
897 |
895 |
$46K |
| D1110 |
Prophylaxis - adult |
502 |
502 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
524 |
523 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
685 |
684 |
$22K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
41 |
33 |
$20K |
| D9999 |
Unspecified adjunctive procedure, by report |
106 |
106 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,913 |
751 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
113 |
42 |
$9K |
| D4341 |
|
208 |
58 |
$9K |
| D1206 |
Topical application of fluoride varnish |
490 |
490 |
$8K |
| D4910 |
|
95 |
95 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
516 |
516 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
77 |
44 |
$4K |
| D0274 |
Bitewings - four radiographic images |
214 |
214 |
$4K |
| D9430 |
|
96 |
92 |
$2K |
| D1120 |
Prophylaxis - child |
15 |
15 |
$718.50 |
| D1999 |
|
95 |
84 |
$280.00 |
| D0220 |
Intraoral - periapical first radiographic image |
20 |
20 |
$154.00 |