| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
160 |
74 |
$76K |
| D0120 |
Periodic oral evaluation - established patient |
1,388 |
1,386 |
$74K |
| D0350 |
|
4,807 |
1,231 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
565 |
261 |
$37K |
| D1110 |
Prophylaxis - adult |
435 |
427 |
$37K |
| D9430 |
|
1,126 |
1,053 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
573 |
573 |
$36K |
| D0210 |
Intraoral - complete series of radiographic images |
768 |
768 |
$35K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
409 |
204 |
$32K |
| D1120 |
Prophylaxis - child |
753 |
749 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,735 |
1,736 |
$27K |
| D0274 |
Bitewings - four radiographic images |
979 |
972 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,487 |
1,477 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
117 |
44 |
$6K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
28 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
33 |
31 |
$390.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$156.00 |
| D1999 |
|
16 |
13 |
$0.00 |