| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
276 |
191 |
$131K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
547 |
545 |
$36K |
| D1110 |
Prophylaxis - adult |
311 |
311 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
350 |
186 |
$23K |
| D0210 |
Intraoral - complete series of radiographic images |
391 |
391 |
$18K |
| D4910 |
|
141 |
141 |
$11K |
| D0350 |
|
846 |
296 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
78 |
76 |
$6K |
| D1206 |
Topical application of fluoride varnish |
320 |
320 |
$6K |
| D1120 |
Prophylaxis - child |
96 |
96 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
314 |
310 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
91 |
47 |
$5K |
| D9430 |
|
70 |
69 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
359 |
127 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
104 |
102 |
$1K |