| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
652 |
625 |
$32K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
30 |
24 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
505 |
477 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
367 |
352 |
$13K |
| D1110 |
Prophylaxis - adult |
125 |
115 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
239 |
231 |
$4K |
| D1120 |
Prophylaxis - child |
137 |
119 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
57 |
25 |
$1K |
| D0274 |
Bitewings - four radiographic images |
169 |
155 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
212 |
191 |
$920.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
331 |
235 |
$786.09 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
14 |
$711.60 |