| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
85 |
59 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
759 |
758 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
298 |
298 |
$17K |
| D1110 |
Prophylaxis - adult |
189 |
189 |
$16K |
| D4341 |
|
239 |
68 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
247 |
247 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,563 |
915 |
$10K |
| D4910 |
|
61 |
61 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
301 |
281 |
$4K |
| D1120 |
Prophylaxis - child |
111 |
109 |
$3K |
| D2954 |
|
17 |
14 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
44 |
44 |
$950.40 |
| D1208 |
Topical application of fluoride, excluding varnish |
84 |
83 |
$676.00 |
| D9430 |
|
13 |
12 |
$416.00 |