| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
491 |
313 |
$233K |
| D1110 |
Prophylaxis - adult |
1,243 |
1,237 |
$98K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,536 |
1,528 |
$96K |
| D0210 |
Intraoral - complete series of radiographic images |
1,137 |
1,127 |
$52K |
| D4341 |
|
680 |
198 |
$45K |
| D2952 |
|
387 |
266 |
$40K |
| D4910 |
|
331 |
330 |
$25K |
| D1206 |
Topical application of fluoride varnish |
758 |
754 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
130 |
95 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
109 |
109 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
36 |
24 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
98 |
98 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
283 |
62 |
$1K |