| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0350 |
|
5,538 |
1,421 |
$50K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
80 |
38 |
$38K |
| D1110 |
Prophylaxis - adult |
394 |
394 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
567 |
562 |
$34K |
| D0210 |
Intraoral - complete series of radiographic images |
539 |
534 |
$25K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
258 |
101 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,856 |
884 |
$17K |
| D2394 |
|
188 |
87 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,095 |
1,089 |
$14K |
| D9430 |
|
259 |
235 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
146 |
146 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
91 |
24 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
34 |
13 |
$4K |
| D0274 |
Bitewings - four radiographic images |
130 |
129 |
$3K |
| D1120 |
Prophylaxis - child |
55 |
55 |
$2K |
| D0330 |
Panoramic radiographic image |
51 |
51 |
$2K |