| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
368 |
229 |
$175K |
| D1110 |
Prophylaxis - adult |
813 |
801 |
$72K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,050 |
1,040 |
$69K |
| D0210 |
Intraoral - complete series of radiographic images |
747 |
738 |
$36K |
| D4341 |
|
355 |
97 |
$25K |
| D4910 |
|
252 |
252 |
$19K |
| D2952 |
|
182 |
128 |
$19K |
| D1206 |
Topical application of fluoride varnish |
1,099 |
1,082 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
238 |
139 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,061 |
604 |
$13K |
| D0274 |
Bitewings - four radiographic images |
408 |
407 |
$9K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
49 |
25 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
14 |
$1K |
| D1120 |
Prophylaxis - child |
15 |
15 |
$787.50 |
| D0350 |
|
54 |
24 |
$480.00 |