| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
233 |
168 |
$109K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
853 |
853 |
$56K |
| D0210 |
Intraoral - complete series of radiographic images |
808 |
808 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
309 |
309 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,080 |
844 |
$17K |
| D9430 |
|
447 |
444 |
$14K |
| D1120 |
Prophylaxis - child |
257 |
257 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
714 |
712 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
142 |
92 |
$10K |
| D2954 |
|
69 |
56 |
$7K |
| D0274 |
Bitewings - four radiographic images |
325 |
325 |
$7K |
| D1110 |
Prophylaxis - adult |
61 |
60 |
$5K |
| D0350 |
|
427 |
214 |
$4K |
| D4910 |
|
37 |
37 |
$3K |
| D1320 |
|
165 |
165 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
144 |
143 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
13 |
$1K |