| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
513 |
513 |
$34K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
66 |
51 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
374 |
208 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
346 |
346 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
269 |
149 |
$15K |
| D4910 |
|
162 |
162 |
$12K |
| D1110 |
Prophylaxis - adult |
133 |
133 |
$12K |
| D0350 |
|
982 |
338 |
$9K |
| D1120 |
Prophylaxis - child |
158 |
158 |
$8K |
| D4341 |
|
97 |
25 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
407 |
407 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,307 |
362 |
$6K |
| D9430 |
|
146 |
146 |
$5K |
| D2954 |
|
34 |
31 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
44 |
29 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
132 |
132 |
$2K |
| D0274 |
Bitewings - four radiographic images |
69 |
69 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
16 |
16 |
$995.00 |