| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
253 |
163 |
$120K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
545 |
545 |
$36K |
| D0210 |
Intraoral - complete series of radiographic images |
394 |
394 |
$19K |
| D4910 |
|
194 |
194 |
$15K |
| D4341 |
|
201 |
77 |
$14K |
| D2954 |
|
124 |
89 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
136 |
53 |
$9K |
| D2740 |
Crown - porcelain/ceramic |
18 |
12 |
$9K |
| D1120 |
Prophylaxis - child |
128 |
128 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
355 |
355 |
$5K |
| D1110 |
Prophylaxis - adult |
55 |
55 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
706 |
157 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
27 |
27 |
$1K |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$540.00 |