| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
354 |
354 |
$23K |
| D1110 |
Prophylaxis - adult |
133 |
133 |
$11K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
18 |
12 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,677 |
275 |
$7K |
| D0274 |
Bitewings - four radiographic images |
199 |
199 |
$4K |
| D1206 |
Topical application of fluoride varnish |
238 |
238 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
53 |
53 |
$3K |
| D1120 |
Prophylaxis - child |
32 |
32 |
$2K |
| D9430 |
|
43 |
40 |
$1K |
| D0350 |
|
138 |
69 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
14 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
63 |
61 |
$756.00 |
| D1320 |
|
37 |
37 |
$647.50 |