| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
623 |
622 |
$41K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
86 |
54 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
322 |
321 |
$25K |
| D1110 |
Prophylaxis - adult |
247 |
246 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
436 |
436 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,423 |
1,026 |
$18K |
| D4910 |
|
177 |
177 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
156 |
89 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
692 |
686 |
$10K |
| D1120 |
Prophylaxis - child |
183 |
183 |
$8K |
| D0274 |
Bitewings - four radiographic images |
342 |
341 |
$6K |
| D9430 |
|
142 |
136 |
$4K |
| D2954 |
|
37 |
27 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
255 |
246 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
17 |
$2K |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$154.00 |