| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
526 |
270 |
$250K |
| D9430 |
|
1,901 |
1,554 |
$60K |
| D1110 |
Prophylaxis - adult |
670 |
667 |
$58K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
593 |
592 |
$35K |
| D0210 |
Intraoral - complete series of radiographic images |
691 |
691 |
$32K |
| D4910 |
|
407 |
407 |
$31K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
300 |
120 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
293 |
113 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
278 |
278 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,348 |
1,335 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,505 |
1,178 |
$14K |
| D2954 |
|
68 |
43 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
598 |
525 |
$7K |
| D0274 |
Bitewings - four radiographic images |
316 |
315 |
$7K |
| D4341 |
|
91 |
26 |
$6K |
| D1320 |
|
412 |
411 |
$6K |
| D0250 |
|
223 |
204 |
$5K |
| D0350 |
|
198 |
79 |
$2K |
| D0270 |
|
267 |
245 |
$1K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$630.00 |