| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
523 |
518 |
$26K |
| D9999 |
Unspecified adjunctive procedure, by report |
170 |
170 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
467 |
462 |
$20K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
37 |
25 |
$14K |
| D1110 |
Prophylaxis - adult |
213 |
213 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
167 |
90 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
400 |
398 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,849 |
769 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
268 |
268 |
$5K |
| D1120 |
Prophylaxis - child |
125 |
125 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
842 |
768 |
$4K |
| D0274 |
Bitewings - four radiographic images |
419 |
414 |
$4K |
| D9430 |
|
104 |
100 |
$2K |
| D1206 |
Topical application of fluoride varnish |
56 |
56 |
$2K |
| D4341 |
|
28 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$131.00 |