| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4910 |
|
196 |
196 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
180 |
57 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
145 |
145 |
$10K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
20 |
13 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
83 |
83 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
64 |
63 |
$3K |
| D1110 |
Prophylaxis - adult |
28 |
28 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
149 |
149 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
374 |
96 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
54 |
54 |
$1K |