| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
634 |
482 |
$301K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,878 |
1,017 |
$125K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,924 |
1,919 |
$122K |
| D1110 |
Prophylaxis - adult |
1,223 |
1,221 |
$105K |
| D0120 |
Periodic oral evaluation - established patient |
1,539 |
1,534 |
$100K |
| D0230 |
Intraoral - periapical each additional radiographic image |
16,577 |
3,069 |
$68K |
| D0210 |
Intraoral - complete series of radiographic images |
1,075 |
1,069 |
$51K |
| D9430 |
|
1,522 |
1,325 |
$49K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
868 |
509 |
$47K |
| D1120 |
Prophylaxis - child |
1,105 |
1,102 |
$46K |
| D0274 |
Bitewings - four radiographic images |
1,993 |
1,986 |
$41K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,777 |
2,772 |
$38K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
112 |
75 |
$13K |
| D4910 |
|
171 |
171 |
$13K |
| D1320 |
|
731 |
731 |
$11K |
| D4341 |
|
148 |
55 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
121 |
82 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
545 |
537 |
$7K |
| D3221 |
|
25 |
24 |
$2K |
| D0350 |
|
23 |
12 |
$220.80 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$146.00 |