| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
282 |
183 |
$134K |
| D0120 |
Periodic oral evaluation - established patient |
729 |
725 |
$46K |
| D2952 |
|
278 |
160 |
$29K |
| D1110 |
Prophylaxis - adult |
302 |
302 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
405 |
402 |
$25K |
| D4341 |
|
340 |
94 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
393 |
389 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
961 |
958 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
189 |
88 |
$12K |
| D4910 |
|
87 |
87 |
$7K |
| D2394 |
|
33 |
26 |
$3K |
| D1120 |
Prophylaxis - child |
54 |
54 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
174 |
89 |
$688.50 |
| D0274 |
Bitewings - four radiographic images |
28 |
28 |
$583.20 |
| D0220 |
Intraoral - periapical first radiographic image |
48 |
45 |
$576.00 |