| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
1,157 |
874 |
$304K |
| D1110 |
Prophylaxis - adult |
4,876 |
4,771 |
$60K |
| D0120 |
Periodic oral evaluation - established patient |
3,794 |
3,702 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,711 |
2,662 |
$35K |
| D0210 |
Intraoral - complete series of radiographic images |
1,537 |
1,514 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
785 |
546 |
$21K |
| D2954 |
|
389 |
329 |
$20K |
| D0274 |
Bitewings - four radiographic images |
2,139 |
2,078 |
$15K |
| D4341 |
|
463 |
188 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
1,149 |
1,097 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
4,398 |
4,260 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,478 |
3,155 |
$10K |
| D1206 |
Topical application of fluoride varnish |
869 |
842 |
$9K |
| D2750 |
|
29 |
20 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
257 |
167 |
$6K |
| D1120 |
Prophylaxis - child |
335 |
324 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
129 |
98 |
$4K |
| D2332 |
|
21 |
12 |
$793.76 |
| D2950 |
|
17 |
13 |
$496.17 |
| D7140 |
Extraction, erupted tooth or exposed root |
21 |
16 |
$336.00 |