| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
113 |
57 |
$54K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
603 |
593 |
$37K |
| D4910 |
|
433 |
420 |
$33K |
| D1110 |
Prophylaxis - adult |
279 |
270 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
295 |
294 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
137 |
121 |
$5K |
| D1120 |
Prophylaxis - child |
137 |
108 |
$4K |
| D1206 |
Topical application of fluoride varnish |
262 |
255 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
66 |
12 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
156 |
128 |
$1K |
| D0272 |
Bitewings - two radiographic images |
59 |
36 |
$450.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
150 |
51 |
$342.00 |