| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
112 |
78 |
$53K |
| D9430 |
|
815 |
697 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
366 |
366 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
201 |
112 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
264 |
264 |
$12K |
| D2954 |
|
102 |
67 |
$11K |
| D1120 |
Prophylaxis - child |
167 |
167 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
86 |
86 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
100 |
47 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,150 |
458 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
208 |
199 |
$2K |
| D0274 |
Bitewings - four radiographic images |
105 |
104 |
$2K |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
58 |
58 |
$877.25 |
| D1206 |
Topical application of fluoride varnish |
42 |
42 |
$679.00 |
| D0350 |
|
68 |
17 |
$537.60 |