| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
478 |
477 |
$29K |
| D9430 |
|
523 |
444 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
240 |
239 |
$11K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
20 |
12 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
72 |
35 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
57 |
29 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
516 |
149 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
157 |
144 |
$2K |
| D0350 |
|
182 |
86 |
$2K |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$1K |
| D1120 |
Prophylaxis - child |
26 |
26 |
$1K |