| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,691 |
1,683 |
$104K |
| D0210 |
Intraoral - complete series of radiographic images |
1,384 |
1,377 |
$64K |
| D1110 |
Prophylaxis - adult |
259 |
255 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
236 |
120 |
$15K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
20 |
12 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
654 |
647 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
85 |
85 |
$5K |
| D4341 |
|
50 |
15 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
13 |
$1K |
| D4910 |
|
13 |
13 |
$924.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
52 |
51 |
$776.10 |
| D0272 |
Bitewings - two radiographic images |
44 |
44 |
$528.00 |
| D1120 |
Prophylaxis - child |
17 |
17 |
$510.00 |