| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
626 |
625 |
$40K |
| D0350 |
|
2,868 |
736 |
$26K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
51 |
40 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
362 |
362 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,516 |
612 |
$10K |
| D4910 |
|
106 |
106 |
$8K |
| D1320 |
|
472 |
472 |
$8K |
| D0330 |
Panoramic radiographic image |
202 |
202 |
$6K |
| D9430 |
|
170 |
151 |
$5K |
| D1206 |
Topical application of fluoride varnish |
249 |
249 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
55 |
30 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
80 |
80 |
$4K |
| D0274 |
Bitewings - four radiographic images |
117 |
117 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
15 |
$2K |
| D1120 |
Prophylaxis - child |
29 |
29 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
27 |
27 |
$416.00 |