| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
448 |
258 |
$211K |
| D4910 |
|
1,361 |
1,342 |
$104K |
| D2330 |
|
821 |
350 |
$62K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
904 |
385 |
$60K |
| D1110 |
Prophylaxis - adult |
613 |
612 |
$52K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
849 |
382 |
$46K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,422 |
1,519 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
603 |
598 |
$35K |
| D2954 |
|
313 |
188 |
$33K |
| D1206 |
Topical application of fluoride varnish |
1,257 |
1,250 |
$20K |
| D4341 |
|
99 |
24 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
105 |
105 |
$7K |
| D0272 |
Bitewings - two radiographic images |
317 |
317 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
265 |
264 |
$3K |
| D0274 |
Bitewings - four radiographic images |
64 |
64 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
24 |
24 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
38 |
37 |
$456.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$390.00 |
| D0350 |
|
29 |
12 |
$162.00 |
| D1999 |
|
16 |
14 |
$0.00 |