| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
163 |
83 |
$78K |
| D1110 |
Prophylaxis - adult |
400 |
396 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
353 |
353 |
$23K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
288 |
113 |
$23K |
| D4910 |
|
203 |
202 |
$16K |
| D0350 |
|
1,159 |
299 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
236 |
236 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
141 |
140 |
$10K |
| D2954 |
|
75 |
39 |
$8K |
| D2394 |
|
91 |
38 |
$8K |
| D4341 |
|
105 |
27 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
519 |
287 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
29 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
94 |
94 |
$2K |
| D9430 |
|
13 |
13 |
$416.00 |