| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
294 |
160 |
$139K |
| D1110 |
Prophylaxis - adult |
824 |
815 |
$71K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
364 |
362 |
$22K |
| D4910 |
|
285 |
283 |
$22K |
| D1206 |
Topical application of fluoride varnish |
1,120 |
1,112 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
270 |
120 |
$18K |
| D2952 |
|
160 |
95 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
267 |
265 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
218 |
218 |
$10K |
| D4341 |
|
42 |
14 |
$3K |
| D2330 |
|
40 |
24 |
$3K |
| D0274 |
Bitewings - four radiographic images |
96 |
94 |
$2K |
| D9110 |
|
31 |
14 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
123 |
121 |
$1K |
| D1120 |
Prophylaxis - child |
15 |
15 |
$435.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
18 |
$133.65 |
| D1999 |
|
43 |
42 |
$30.00 |