| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
117 |
72 |
$56K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
450 |
450 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
376 |
161 |
$25K |
| D1110 |
Prophylaxis - adult |
288 |
288 |
$24K |
| D4341 |
|
282 |
76 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
315 |
315 |
$15K |
| D4910 |
|
177 |
177 |
$14K |
| D9430 |
|
418 |
338 |
$13K |
| D2954 |
|
106 |
69 |
$11K |
| D1320 |
|
440 |
440 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
74 |
74 |
$6K |
| D1206 |
Topical application of fluoride varnish |
356 |
356 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,327 |
368 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
399 |
328 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
35 |
21 |
$3K |
| D1120 |
Prophylaxis - child |
27 |
27 |
$1K |
| D0274 |
Bitewings - four radiographic images |
70 |
70 |
$1K |