| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4910 |
|
734 |
732 |
$56K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
91 |
54 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
409 |
407 |
$27K |
| D1110 |
Prophylaxis - adult |
135 |
134 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,031 |
363 |
$8K |
| D1120 |
Prophylaxis - child |
129 |
126 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
81 |
81 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
336 |
333 |
$4K |
| D0272 |
Bitewings - two radiographic images |
218 |
217 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
42 |
42 |
$2K |
| D1206 |
Topical application of fluoride varnish |
83 |
82 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$1K |
| D9430 |
|
12 |
12 |
$384.00 |
| D1320 |
|
13 |
13 |
$227.50 |