| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
653 |
547 |
$308K |
| D2740 |
Crown - porcelain/ceramic |
230 |
204 |
$135K |
| D1110 |
Prophylaxis - adult |
2,716 |
2,659 |
$133K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
949 |
557 |
$115K |
| D0120 |
Periodic oral evaluation - established patient |
3,959 |
3,867 |
$92K |
| D1206 |
Topical application of fluoride varnish |
2,723 |
2,664 |
$54K |
| D0210 |
Intraoral - complete series of radiographic images |
709 |
694 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,059 |
1,030 |
$34K |
| D0274 |
Bitewings - four radiographic images |
1,005 |
990 |
$32K |
| D2950 |
|
275 |
248 |
$30K |
| D0140 |
Limited oral evaluation - problem focused |
860 |
822 |
$28K |
| D5226 |
|
29 |
29 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
792 |
753 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
47 |
38 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
67 |
26 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
73 |
49 |
$5K |
| D1120 |
Prophylaxis - child |
63 |
63 |
$2K |
| D4910 |
|
14 |
14 |
$913.78 |