| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
724 |
720 |
$36K |
| D0350 |
|
3,480 |
927 |
$32K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
56 |
29 |
$27K |
| D1120 |
Prophylaxis - child |
728 |
724 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,435 |
1,157 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
192 |
73 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
188 |
188 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
765 |
761 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
78 |
40 |
$6K |
| D4910 |
|
81 |
81 |
$6K |
| D2954 |
|
51 |
27 |
$5K |
| D0274 |
Bitewings - four radiographic images |
278 |
278 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
108 |
108 |
$5K |
| D1110 |
Prophylaxis - adult |
41 |
41 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
193 |
189 |
$2K |
| D1206 |
Topical application of fluoride varnish |
43 |
43 |
$716.00 |
| D0272 |
Bitewings - two radiographic images |
43 |
43 |
$408.00 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$390.00 |