| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,195 |
1,194 |
$78K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
156 |
113 |
$74K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,066 |
551 |
$69K |
| D1110 |
Prophylaxis - adult |
548 |
547 |
$47K |
| D0210 |
Intraoral - complete series of radiographic images |
925 |
925 |
$44K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
356 |
178 |
$19K |
| D9430 |
|
541 |
485 |
$17K |
| D2954 |
|
137 |
107 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
196 |
196 |
$14K |
| D0330 |
Panoramic radiographic image |
461 |
460 |
$11K |
| D2740 |
Crown - porcelain/ceramic |
21 |
12 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
502 |
502 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,653 |
849 |
$7K |
| D0274 |
Bitewings - four radiographic images |
242 |
242 |
$5K |
| D4910 |
|
43 |
43 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
44 |
29 |
$3K |
| D1120 |
Prophylaxis - child |
45 |
45 |
$2K |
| D2332 |
|
19 |
12 |
$2K |
| D0350 |
|
150 |
40 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
70 |
68 |
$840.00 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$208.00 |
| D0190 |
|
151 |
144 |
$0.00 |
| D1999 |
|
149 |
142 |
$0.00 |