| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
420 |
165 |
$199K |
| D4910 |
|
2,580 |
2,580 |
$198K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
278 |
278 |
$17K |
| D0350 |
|
1,975 |
580 |
$17K |
| D4341 |
|
224 |
63 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,616 |
646 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
134 |
134 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
94 |
90 |
$4K |
| D9430 |
|
105 |
88 |
$3K |
| D1206 |
Topical application of fluoride varnish |
205 |
205 |
$3K |
| D2952 |
|
18 |
12 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
49 |
49 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
41 |
38 |
$492.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$360.00 |