| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
224 |
137 |
$107K |
| D0120 |
Periodic oral evaluation - established patient |
1,518 |
1,506 |
$86K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
979 |
977 |
$61K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,522 |
2,413 |
$46K |
| D0350 |
|
4,327 |
1,139 |
$41K |
| D1120 |
Prophylaxis - child |
1,093 |
1,086 |
$39K |
| D0210 |
Intraoral - complete series of radiographic images |
809 |
808 |
$38K |
| D1110 |
Prophylaxis - adult |
419 |
415 |
$33K |
| D9430 |
|
685 |
652 |
$21K |
| D2954 |
|
160 |
106 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
246 |
123 |
$16K |
| D0274 |
Bitewings - four radiographic images |
742 |
739 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,230 |
1,221 |
$13K |
| D4910 |
|
155 |
155 |
$12K |
| D4341 |
|
132 |
37 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
380 |
374 |
$4K |
| D1351 |
Sealant - per tooth |
198 |
42 |
$4K |
| D1206 |
Topical application of fluoride varnish |
158 |
157 |
$3K |
| D0272 |
Bitewings - two radiographic images |
85 |
83 |
$948.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$928.20 |