| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
619 |
617 |
$51K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
337 |
336 |
$20K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
34 |
12 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
213 |
211 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
144 |
144 |
$9K |
| D1206 |
Topical application of fluoride varnish |
369 |
369 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
52 |
25 |
$4K |
| D2394 |
|
37 |
19 |
$3K |
| D2952 |
|
22 |
14 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
68 |
65 |
$752.00 |
| D5851 |
|
12 |
12 |
$630.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
49 |
49 |
$501.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$120.00 |