| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
409 |
268 |
$193K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,280 |
626 |
$84K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,111 |
1,104 |
$72K |
| D0120 |
Periodic oral evaluation - established patient |
731 |
730 |
$57K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
866 |
441 |
$46K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
374 |
136 |
$44K |
| D0210 |
Intraoral - complete series of radiographic images |
923 |
917 |
$44K |
| D4341 |
|
562 |
155 |
$39K |
| D4910 |
|
509 |
509 |
$38K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,414 |
873 |
$18K |
| D0274 |
Bitewings - four radiographic images |
823 |
822 |
$17K |
| D1120 |
Prophylaxis - child |
227 |
227 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
143 |
96 |
$11K |
| D1110 |
Prophylaxis - adult |
88 |
88 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
488 |
488 |
$7K |
| D9430 |
|
80 |
77 |
$3K |
| D2331 |
|
19 |
12 |
$2K |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$226.00 |