| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
528 |
318 |
$251K |
| D1110 |
Prophylaxis - adult |
735 |
730 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
747 |
744 |
$38K |
| D2954 |
|
139 |
103 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,795 |
792 |
$14K |
| D1206 |
Topical application of fluoride varnish |
791 |
788 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
104 |
104 |
$5K |
| D2920 |
|
118 |
95 |
$5K |
| D0274 |
Bitewings - four radiographic images |
174 |
174 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
47 |
47 |
$3K |
| D9430 |
|
59 |
57 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
27 |
$308.00 |