| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
320 |
270 |
$163K |
| D1110 |
Prophylaxis - adult |
3,641 |
3,639 |
$158K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,294 |
889 |
$93K |
| D0120 |
Periodic oral evaluation - established patient |
2,855 |
2,855 |
$62K |
| D0274 |
Bitewings - four radiographic images |
1,773 |
1,772 |
$38K |
| D0210 |
Intraoral - complete series of radiographic images |
1,088 |
1,078 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,553 |
1,551 |
$35K |
| D0220 |
Intraoral - periapical first radiographic image |
2,707 |
2,697 |
$28K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
190 |
156 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
356 |
257 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,326 |
1,326 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,103 |
2,092 |
$14K |
| D1120 |
Prophylaxis - child |
428 |
428 |
$14K |
| D2954 |
|
31 |
28 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
131 |
129 |
$1K |
| D2331 |
|
17 |
13 |
$1K |
| D0270 |
|
13 |
13 |
$136.11 |