| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
193 |
110 |
$91K |
| D4910 |
|
385 |
385 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
400 |
400 |
$26K |
| D1110 |
Prophylaxis - adult |
268 |
268 |
$22K |
| D2954 |
|
180 |
108 |
$18K |
| D4341 |
|
225 |
58 |
$16K |
| D9430 |
|
402 |
371 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
173 |
83 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
124 |
124 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
423 |
423 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
748 |
457 |
$5K |
| D0350 |
|
176 |
133 |
$4K |
| D0274 |
Bitewings - four radiographic images |
105 |
105 |
$2K |