| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
867 |
856 |
$56K |
| D2740 |
Crown - porcelain/ceramic |
81 |
50 |
$38K |
| D0210 |
Intraoral - complete series of radiographic images |
777 |
768 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
305 |
305 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
306 |
179 |
$20K |
| D4910 |
|
199 |
199 |
$15K |
| D1110 |
Prophylaxis - adult |
145 |
145 |
$13K |
| D9430 |
|
345 |
326 |
$11K |
| D4341 |
|
114 |
38 |
$8K |
| D1206 |
Topical application of fluoride varnish |
470 |
468 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
907 |
402 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
38 |
30 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
19 |
15 |
$2K |
| D0274 |
Bitewings - four radiographic images |
95 |
95 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
83 |
83 |
$978.00 |
| D0220 |
Intraoral - periapical first radiographic image |
24 |
24 |
$288.00 |