| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
325 |
251 |
$86K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,463 |
1,461 |
$21K |
| D4355 |
|
434 |
431 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
1,133 |
1,131 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
1,049 |
1,036 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
1,073 |
789 |
$17K |
| D1110 |
Prophylaxis - adult |
892 |
884 |
$9K |
| D0274 |
Bitewings - four radiographic images |
982 |
969 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,976 |
1,906 |
$6K |
| D2954 |
|
140 |
120 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
140 |
82 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,230 |
1,209 |
$3K |
| D1206 |
Topical application of fluoride varnish |
233 |
233 |
$2K |
| D1120 |
Prophylaxis - child |
210 |
210 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
58 |
24 |
$2K |
| D1351 |
Sealant - per tooth |
83 |
12 |
$540.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
21 |
14 |
$300.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
260 |
259 |
$102.00 |