| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
607 |
397 |
$283K |
| D4910 |
|
1,747 |
1,735 |
$131K |
| D4341 |
|
1,377 |
375 |
$95K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
934 |
925 |
$58K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,070 |
462 |
$56K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
772 |
437 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
773 |
770 |
$48K |
| D9430 |
|
1,097 |
1,000 |
$35K |
| D0210 |
Intraoral - complete series of radiographic images |
717 |
709 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,194 |
1,406 |
$27K |
| D0350 |
|
2,339 |
985 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,146 |
1,079 |
$14K |
| D1206 |
Topical application of fluoride varnish |
556 |
554 |
$8K |
| D2330 |
|
103 |
40 |
$8K |
| D0274 |
Bitewings - four radiographic images |
291 |
291 |
$6K |
| D0272 |
Bitewings - two radiographic images |
436 |
435 |
$5K |
| D9951 |
|
178 |
165 |
$5K |
| D1110 |
Prophylaxis - adult |
63 |
63 |
$4K |
| D1120 |
Prophylaxis - child |
57 |
57 |
$3K |
| D2332 |
|
18 |
12 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
15 |
$1K |