| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
537 |
426 |
$199K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,956 |
1,480 |
$190K |
| D1110 |
Prophylaxis - adult |
3,681 |
3,678 |
$140K |
| D0120 |
Periodic oral evaluation - established patient |
4,016 |
4,013 |
$84K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,017 |
1,025 |
$84K |
| D2335 |
|
915 |
513 |
$82K |
| D2330 |
|
1,205 |
683 |
$54K |
| D2332 |
|
726 |
423 |
$51K |
| D0274 |
Bitewings - four radiographic images |
2,799 |
2,798 |
$47K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,649 |
3,640 |
$45K |
| D0210 |
Intraoral - complete series of radiographic images |
3,481 |
3,476 |
$44K |
| D0220 |
Intraoral - periapical first radiographic image |
3,916 |
3,905 |
$32K |
| D1120 |
Prophylaxis - child |
953 |
953 |
$30K |
| D2394 |
|
362 |
228 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,634 |
1,634 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
981 |
981 |
$20K |
| D1351 |
Sealant - per tooth |
398 |
98 |
$15K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
106 |
79 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
411 |
408 |
$6K |
| D1206 |
Topical application of fluoride varnish |
59 |
59 |
$2K |
| D0272 |
Bitewings - two radiographic images |
133 |
133 |
$2K |
| D2161 |
|
19 |
12 |
$1K |
| D2331 |
|
14 |
12 |
$806.07 |