| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
440 |
261 |
$209K |
| D1110 |
Prophylaxis - adult |
1,605 |
1,594 |
$137K |
| D0120 |
Periodic oral evaluation - established patient |
1,277 |
1,263 |
$76K |
| D4910 |
|
534 |
530 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
663 |
659 |
$40K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,039 |
2,023 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,837 |
1,114 |
$24K |
| D0274 |
Bitewings - four radiographic images |
728 |
723 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
333 |
330 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
177 |
88 |
$12K |
| D2952 |
|
18 |
12 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
14 |
14 |
$420.00 |