| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
142 |
92 |
$68K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
705 |
702 |
$46K |
| D1110 |
Prophylaxis - adult |
444 |
444 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
458 |
458 |
$38K |
| D0210 |
Intraoral - complete series of radiographic images |
497 |
497 |
$24K |
| D9430 |
|
705 |
536 |
$23K |
| D1120 |
Prophylaxis - child |
426 |
423 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,059 |
1,056 |
$16K |
| D0274 |
Bitewings - four radiographic images |
493 |
492 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,139 |
924 |
$9K |
| D4910 |
|
110 |
110 |
$8K |
| D0350 |
|
882 |
364 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
139 |
55 |
$8K |
| D4341 |
|
107 |
29 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
59 |
33 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
284 |
255 |
$3K |
| D1351 |
Sealant - per tooth |
56 |
14 |
$2K |