| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
640 |
372 |
$304K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,013 |
995 |
$134K |
| D1110 |
Prophylaxis - adult |
1,011 |
1,008 |
$89K |
| D4910 |
|
974 |
969 |
$75K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,102 |
1,086 |
$68K |
| D0120 |
Periodic oral evaluation - established patient |
900 |
897 |
$57K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
975 |
475 |
$52K |
| D0210 |
Intraoral - complete series of radiographic images |
931 |
919 |
$43K |
| D0350 |
|
4,206 |
1,363 |
$40K |
| D2954 |
|
279 |
186 |
$29K |
| D4341 |
|
395 |
108 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,060 |
2,047 |
$27K |
| D1120 |
Prophylaxis - child |
584 |
579 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
266 |
179 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,400 |
2,237 |
$18K |
| D9430 |
|
519 |
500 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,298 |
1,196 |
$15K |
| D0274 |
Bitewings - four radiographic images |
652 |
650 |
$14K |
| D3320 |
|
12 |
12 |
$4K |
| D0330 |
Panoramic radiographic image |
101 |
101 |
$3K |
| D2330 |
|
24 |
14 |
$2K |