| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
249 |
209 |
$162K |
| D1110 |
Prophylaxis - adult |
1,599 |
1,597 |
$85K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
464 |
390 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
1,339 |
1,337 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
255 |
203 |
$26K |
| D0274 |
Bitewings - four radiographic images |
373 |
373 |
$10K |
| D0330 |
Panoramic radiographic image |
212 |
212 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
243 |
243 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
458 |
455 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
55 |
50 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
133 |
133 |
$2K |
| D2394 |
|
15 |
12 |
$2K |