| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
294 |
289 |
$7K |
| D1120 |
Prophylaxis - child |
159 |
158 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
128 |
125 |
$4K |
| D2740 |
Crown - porcelain/ceramic |
13 |
13 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
67 |
66 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
15 |
$2K |
| D1206 |
Topical application of fluoride varnish |
30 |
30 |
$780.00 |
| D0330 |
Panoramic radiographic image |
51 |
50 |
$723.20 |
| D1110 |
Prophylaxis - adult |
26 |
25 |
$656.00 |