| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
681 |
494 |
$323K |
| D1110 |
Prophylaxis - adult |
2,286 |
2,274 |
$193K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,260 |
976 |
$150K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,209 |
2,200 |
$143K |
| D0120 |
Periodic oral evaluation - established patient |
1,882 |
1,878 |
$118K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
997 |
496 |
$118K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,180 |
890 |
$118K |
| D0210 |
Intraoral - complete series of radiographic images |
1,793 |
1,784 |
$86K |
| D0230 |
Intraoral - periapical each additional radiographic image |
16,204 |
2,886 |
$66K |
| D1120 |
Prophylaxis - child |
1,563 |
1,560 |
$60K |
| D2954 |
|
427 |
334 |
$45K |
| D4341 |
|
464 |
129 |
$32K |
| D0274 |
Bitewings - four radiographic images |
566 |
563 |
$12K |
| D0272 |
Bitewings - two radiographic images |
879 |
877 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
840 |
837 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
788 |
773 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
102 |
62 |
$8K |
| D1320 |
|
395 |
395 |
$6K |
| D2331 |
|
64 |
35 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
58 |
26 |
$3K |
| D0350 |
|
299 |
138 |
$3K |
| D4910 |
|
22 |
22 |
$2K |
| D9430 |
|
26 |
26 |
$832.00 |