| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
362 |
246 |
$170K |
| D2952 |
|
344 |
246 |
$36K |
| D4910 |
|
443 |
441 |
$33K |
| D1110 |
Prophylaxis - adult |
272 |
271 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
450 |
444 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
144 |
114 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
157 |
152 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
453 |
451 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
89 |
86 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
277 |
269 |
$3K |
| D4341 |
|
44 |
13 |
$3K |
| D5751 |
|
12 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
238 |
65 |
$880.35 |