| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
820 |
820 |
$54K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
975 |
367 |
$53K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
101 |
70 |
$48K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
317 |
175 |
$21K |
| D0350 |
|
2,264 |
658 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
433 |
433 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
180 |
180 |
$14K |
| D1110 |
Prophylaxis - adult |
124 |
123 |
$11K |
| D1120 |
Prophylaxis - child |
187 |
187 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,765 |
524 |
$7K |
| D2954 |
|
47 |
37 |
$5K |
| D9430 |
|
98 |
81 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
112 |
111 |
$2K |
| D0274 |
Bitewings - four radiographic images |
46 |
46 |
$950.40 |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$276.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$144.00 |
| D1330 |
|
46 |
46 |
$0.00 |