| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
501 |
330 |
$238K |
| D1110 |
Prophylaxis - adult |
1,364 |
1,361 |
$111K |
| D4341 |
|
986 |
271 |
$65K |
| D2952 |
|
490 |
326 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
815 |
812 |
$46K |
| D4910 |
|
431 |
422 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,045 |
1,352 |
$28K |
| D9110 |
|
293 |
241 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,189 |
1,180 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
280 |
279 |
$16K |
| D0274 |
Bitewings - four radiographic images |
731 |
728 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
215 |
214 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
287 |
283 |
$3K |
| D1206 |
Topical application of fluoride varnish |
264 |
264 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
52 |
14 |
$3K |
| D9430 |
|
70 |
69 |
$2K |
| D2330 |
|
28 |
17 |
$2K |
| D0350 |
|
18 |
14 |
$222.00 |