| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
642 |
641 |
$40K |
| D0210 |
Intraoral - complete series of radiographic images |
536 |
534 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
165 |
164 |
$11K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
17 |
12 |
$8K |
| D1110 |
Prophylaxis - adult |
67 |
67 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
422 |
417 |
$5K |
| D0350 |
|
504 |
127 |
$5K |
| D1120 |
Prophylaxis - child |
114 |
114 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
975 |
178 |
$4K |
| D4341 |
|
45 |
12 |
$3K |
| D2954 |
|
27 |
13 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
64 |
64 |
$1K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$390.00 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$216.00 |