| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
900 |
565 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
383 |
383 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
611 |
610 |
$9K |
| D4355 |
|
118 |
118 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
382 |
382 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
141 |
67 |
$6K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
18 |
13 |
$6K |
| D1110 |
Prophylaxis - adult |
289 |
287 |
$5K |
| D0274 |
Bitewings - four radiographic images |
463 |
463 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
962 |
944 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
13 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
493 |
492 |
$1K |
| D1120 |
Prophylaxis - child |
48 |
48 |
$905.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
55 |
55 |
$675.00 |
| D1206 |
Topical application of fluoride varnish |
63 |
63 |
$530.00 |