| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
254 |
163 |
$121K |
| D0120 |
Periodic oral evaluation - established patient |
1,943 |
1,939 |
$107K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,231 |
450 |
$80K |
| D9430 |
|
2,422 |
1,997 |
$77K |
| D1110 |
Prophylaxis - adult |
808 |
804 |
$65K |
| D1120 |
Prophylaxis - child |
1,405 |
1,401 |
$53K |
| D0210 |
Intraoral - complete series of radiographic images |
1,115 |
1,114 |
$52K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,280 |
2,263 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
633 |
630 |
$39K |
| D1206 |
Topical application of fluoride varnish |
2,496 |
2,487 |
$33K |
| D4341 |
|
449 |
171 |
$31K |
| D2952 |
|
252 |
162 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
433 |
170 |
$23K |
| D1351 |
Sealant - per tooth |
570 |
139 |
$16K |
| D0272 |
Bitewings - two radiographic images |
1,252 |
1,247 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
131 |
56 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
738 |
711 |
$9K |
| D0350 |
|
490 |
149 |
$6K |
| D2160 |
|
19 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
16 |
16 |
$345.60 |