| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
809 |
803 |
$49K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
517 |
233 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
456 |
454 |
$21K |
| D0350 |
|
2,361 |
673 |
$21K |
| D9430 |
|
620 |
551 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
393 |
390 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,198 |
1,106 |
$14K |
| D1120 |
Prophylaxis - child |
363 |
360 |
$12K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
21 |
15 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
797 |
794 |
$10K |
| D0274 |
Bitewings - four radiographic images |
399 |
397 |
$7K |
| D1110 |
Prophylaxis - adult |
62 |
62 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
53 |
26 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
112 |
108 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$144.00 |