| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
382 |
260 |
$182K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,502 |
1,497 |
$99K |
| D1110 |
Prophylaxis - adult |
754 |
750 |
$66K |
| D0210 |
Intraoral - complete series of radiographic images |
1,340 |
1,337 |
$63K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
804 |
456 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
509 |
502 |
$39K |
| D1120 |
Prophylaxis - child |
540 |
528 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,207 |
698 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,401 |
1,382 |
$21K |
| D2954 |
|
191 |
142 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
234 |
148 |
$13K |
| D4341 |
|
173 |
46 |
$12K |
| D0272 |
Bitewings - two radiographic images |
587 |
576 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
30 |
26 |
$2K |
| D2331 |
|
21 |
13 |
$2K |