| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
402 |
354 |
$191K |
| D1110 |
Prophylaxis - adult |
2,057 |
2,046 |
$175K |
| D0120 |
Periodic oral evaluation - established patient |
2,698 |
2,679 |
$174K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,536 |
2,520 |
$159K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,029 |
1,185 |
$133K |
| D1120 |
Prophylaxis - child |
2,509 |
2,498 |
$105K |
| D0210 |
Intraoral - complete series of radiographic images |
2,263 |
2,253 |
$104K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,846 |
1,072 |
$98K |
| D4910 |
|
1,149 |
1,143 |
$87K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,869 |
4,834 |
$65K |
| D0350 |
|
5,539 |
2,360 |
$53K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,071 |
3,477 |
$46K |
| D0274 |
Bitewings - four radiographic images |
2,178 |
2,163 |
$42K |
| D9430 |
|
1,228 |
1,178 |
$39K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
328 |
159 |
$38K |
| D0330 |
Panoramic radiographic image |
939 |
936 |
$28K |
| D4341 |
|
371 |
112 |
$26K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
268 |
216 |
$21K |
| D2954 |
|
152 |
133 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,084 |
1,041 |
$13K |
| D1320 |
|
806 |
805 |
$13K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
102 |
40 |
$7K |
| D0272 |
Bitewings - two radiographic images |
370 |
368 |
$4K |
| D9993 |
|
19 |
19 |
$1K |
| D1310 |
|
19 |
19 |
$874.00 |
| D1354 |
|
33 |
12 |
$372.00 |