| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
659 |
658 |
$43K |
| D0210 |
Intraoral - complete series of radiographic images |
589 |
588 |
$26K |
| D1110 |
Prophylaxis - adult |
300 |
300 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
364 |
158 |
$24K |
| D4341 |
|
172 |
46 |
$12K |
| D9430 |
|
344 |
299 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
731 |
726 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
188 |
73 |
$10K |
| D4910 |
|
126 |
126 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
114 |
114 |
$9K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
16 |
12 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,223 |
380 |
$5K |
| D1120 |
Prophylaxis - child |
76 |
75 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
118 |
105 |
$1K |
| D0274 |
Bitewings - four radiographic images |
71 |
71 |
$1K |
| D0350 |
|
71 |
26 |
$576.00 |