| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
282 |
169 |
$133K |
| D1110 |
Prophylaxis - adult |
1,138 |
1,110 |
$93K |
| D0120 |
Periodic oral evaluation - established patient |
1,008 |
991 |
$53K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,710 |
1,673 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
336 |
310 |
$17K |
| D0274 |
Bitewings - four radiographic images |
561 |
556 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,737 |
1,288 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
219 |
204 |
$9K |
| D9430 |
|
151 |
145 |
$5K |
| D4910 |
|
39 |
39 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
75 |
29 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
54 |
26 |
$3K |
| D2331 |
|
39 |
13 |
$3K |
| D1120 |
Prophylaxis - child |
51 |
51 |
$2K |
| D2954 |
|
14 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
72 |
70 |
$879.00 |