| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
418 |
298 |
$198K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,593 |
871 |
$105K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,092 |
1,088 |
$71K |
| D1110 |
Prophylaxis - adult |
761 |
757 |
$67K |
| D0120 |
Periodic oral evaluation - established patient |
942 |
938 |
$54K |
| D1120 |
Prophylaxis - child |
1,083 |
1,078 |
$41K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,195 |
2,041 |
$33K |
| D0274 |
Bitewings - four radiographic images |
1,603 |
1,594 |
$32K |
| D1206 |
Topical application of fluoride varnish |
1,942 |
1,931 |
$26K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
326 |
220 |
$26K |
| D2954 |
|
138 |
106 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
289 |
288 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
228 |
146 |
$12K |
| D9430 |
|
201 |
198 |
$6K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
28 |
16 |
$2K |
| D2394 |
|
14 |
12 |
$1K |
| D0240 |
|
87 |
43 |
$630.00 |
| D0220 |
Intraoral - periapical first radiographic image |
20 |
20 |
$228.00 |