| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
499 |
409 |
$237K |
| D0120 |
Periodic oral evaluation - established patient |
3,630 |
3,618 |
$199K |
| D1110 |
Prophylaxis - adult |
2,065 |
2,055 |
$178K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,274 |
1,271 |
$79K |
| D1120 |
Prophylaxis - child |
1,854 |
1,849 |
$70K |
| D0230 |
Intraoral - periapical each additional radiographic image |
14,914 |
4,143 |
$61K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
901 |
728 |
$60K |
| D9430 |
|
1,881 |
1,830 |
$60K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,067 |
875 |
$57K |
| D0274 |
Bitewings - four radiographic images |
2,585 |
2,576 |
$55K |
| D0210 |
Intraoral - complete series of radiographic images |
1,129 |
1,123 |
$53K |
| D4341 |
|
601 |
187 |
$42K |
| D0220 |
Intraoral - periapical first radiographic image |
2,942 |
2,840 |
$35K |
| D4910 |
|
403 |
401 |
$30K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
371 |
327 |
$29K |
| D2330 |
|
301 |
196 |
$23K |
| D2954 |
|
206 |
174 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,900 |
1,892 |
$21K |
| D0350 |
|
946 |
751 |
$9K |
| D9110 |
|
88 |
84 |
$6K |
| D0272 |
Bitewings - two radiographic images |
329 |
328 |
$4K |
| D1351 |
Sealant - per tooth |
80 |
24 |
$2K |