| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
456 |
365 |
$209K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,041 |
563 |
$67K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
707 |
703 |
$46K |
| D4341 |
|
603 |
217 |
$41K |
| D9430 |
|
1,145 |
1,061 |
$35K |
| D0210 |
Intraoral - complete series of radiographic images |
768 |
765 |
$35K |
| D4910 |
|
428 |
422 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
454 |
452 |
$29K |
| D2954 |
|
172 |
140 |
$18K |
| D1110 |
Prophylaxis - adult |
193 |
193 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,955 |
1,046 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
286 |
133 |
$15K |
| D3221 |
|
108 |
92 |
$7K |
| D0274 |
Bitewings - four radiographic images |
306 |
305 |
$6K |
| D2330 |
|
73 |
40 |
$5K |
| D0350 |
|
575 |
213 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
362 |
350 |
$4K |
| D0270 |
|
376 |
359 |
$2K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$360.00 |