| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
502 |
243 |
$270K |
| D1110 |
Prophylaxis - adult |
3,085 |
2,875 |
$150K |
| D2740 |
Crown - porcelain/ceramic |
167 |
72 |
$97K |
| D0274 |
Bitewings - four radiographic images |
1,832 |
1,720 |
$60K |
| D0120 |
Periodic oral evaluation - established patient |
2,876 |
2,688 |
$59K |
| D0220 |
Intraoral - periapical first radiographic image |
2,832 |
2,536 |
$39K |
| D0210 |
Intraoral - complete series of radiographic images |
591 |
546 |
$38K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,423 |
2,012 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
190 |
168 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
181 |
165 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
69 |
60 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$408.00 |