| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
408 |
408 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
171 |
170 |
$13K |
| D2740 |
Crown - porcelain/ceramic |
21 |
13 |
$10K |
| D1110 |
Prophylaxis - adult |
102 |
102 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
133 |
63 |
$9K |
| D1120 |
Prophylaxis - child |
164 |
163 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
168 |
167 |
$8K |
| D0274 |
Bitewings - four radiographic images |
164 |
164 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
186 |
186 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
507 |
255 |
$2K |
| D2954 |
|
17 |
12 |
$2K |
| D1206 |
Topical application of fluoride varnish |
68 |
67 |
$1K |