| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
570 |
570 |
$37K |
| D0210 |
Intraoral - complete series of radiographic images |
464 |
464 |
$22K |
| D1110 |
Prophylaxis - adult |
220 |
219 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
303 |
155 |
$19K |
| D0350 |
|
1,621 |
449 |
$14K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
18 |
12 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
50 |
33 |
$4K |
| D1206 |
Topical application of fluoride varnish |
204 |
204 |
$3K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$630.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
111 |
65 |
$494.10 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$206.00 |