| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
673 |
664 |
$44K |
| D0210 |
Intraoral - complete series of radiographic images |
620 |
613 |
$28K |
| D1110 |
Prophylaxis - adult |
300 |
297 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
314 |
192 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
210 |
126 |
$11K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
21 |
13 |
$10K |
| D1206 |
Topical application of fluoride varnish |
542 |
534 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
40 |
25 |
$3K |
| D1120 |
Prophylaxis - child |
61 |
60 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
27 |
27 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
265 |
88 |
$1K |
| D0274 |
Bitewings - four radiographic images |
31 |
31 |
$410.40 |
| D9430 |
|
12 |
12 |
$384.00 |