| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
237 |
132 |
$113K |
| D0120 |
Periodic oral evaluation - established patient |
426 |
426 |
$27K |
| D2954 |
|
179 |
106 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
413 |
413 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
228 |
228 |
$14K |
| D4341 |
|
136 |
37 |
$10K |
| D4910 |
|
88 |
88 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
396 |
396 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
46 |
27 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
734 |
163 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
51 |
25 |
$3K |
| D1120 |
Prophylaxis - child |
61 |
61 |
$2K |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
39 |
39 |
$842.40 |