| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
218 |
155 |
$104K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
603 |
600 |
$38K |
| D0210 |
Intraoral - complete series of radiographic images |
557 |
557 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
395 |
386 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,192 |
987 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
189 |
115 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
977 |
968 |
$12K |
| D9430 |
|
374 |
362 |
$12K |
| D1120 |
Prophylaxis - child |
317 |
310 |
$11K |
| D4910 |
|
132 |
131 |
$10K |
| D1110 |
Prophylaxis - adult |
107 |
107 |
$10K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
119 |
51 |
$6K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
13 |
12 |
$6K |
| D2954 |
|
57 |
44 |
$6K |
| D2140 |
|
100 |
42 |
$5K |
| D0274 |
Bitewings - four radiographic images |
231 |
225 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
170 |
166 |
$2K |
| D0350 |
|
183 |
87 |
$2K |
| D2160 |
|
20 |
15 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
15 |
$1K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$390.00 |
| D0272 |
Bitewings - two radiographic images |
29 |
29 |
$304.00 |