| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
148 |
105 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
374 |
369 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
374 |
373 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
297 |
161 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
306 |
306 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
618 |
612 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,153 |
539 |
$9K |
| D4341 |
|
142 |
61 |
$7K |
| D1120 |
Prophylaxis - child |
149 |
146 |
$6K |
| D9430 |
|
203 |
186 |
$6K |
| D1110 |
Prophylaxis - adult |
47 |
47 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
53 |
29 |
$3K |
| D0274 |
Bitewings - four radiographic images |
123 |
120 |
$3K |
| D0350 |
|
187 |
73 |
$2K |
| D1999 |
|
75 |
65 |
$40.00 |