| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
572 |
366 |
$272K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,613 |
1,137 |
$174K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,218 |
1,114 |
$174K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,418 |
1,411 |
$93K |
| D1110 |
Prophylaxis - adult |
792 |
785 |
$70K |
| D0350 |
|
6,718 |
1,913 |
$65K |
| D0120 |
Periodic oral evaluation - established patient |
780 |
776 |
$63K |
| D0210 |
Intraoral - complete series of radiographic images |
1,182 |
1,176 |
$56K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
551 |
339 |
$44K |
| D4341 |
|
564 |
183 |
$39K |
| D4910 |
|
384 |
384 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,560 |
1,550 |
$25K |
| D1120 |
Prophylaxis - child |
478 |
473 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,144 |
898 |
$21K |
| D0274 |
Bitewings - four radiographic images |
719 |
714 |
$15K |
| D9430 |
|
378 |
369 |
$12K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
50 |
28 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
452 |
442 |
$5K |
| D2330 |
|
56 |
36 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
18 |
18 |
$172.00 |