| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
793 |
791 |
$52K |
| D1110 |
Prophylaxis - adult |
565 |
563 |
$50K |
| D0210 |
Intraoral - complete series of radiographic images |
735 |
734 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
392 |
222 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
257 |
256 |
$20K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
29 |
26 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
857 |
854 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
189 |
97 |
$10K |
| D1120 |
Prophylaxis - child |
134 |
134 |
$7K |
| D0274 |
Bitewings - four radiographic images |
154 |
154 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
471 |
261 |
$2K |
| D1206 |
Topical application of fluoride varnish |
97 |
97 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$1K |
| D9430 |
|
21 |
20 |
$672.00 |
| D0220 |
Intraoral - periapical first radiographic image |
20 |
20 |
$240.00 |
| D0330 |
Panoramic radiographic image |
22 |
22 |
$15.00 |