| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
229 |
157 |
$109K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,527 |
730 |
$101K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,426 |
1,419 |
$88K |
| D0120 |
Periodic oral evaluation - established patient |
1,442 |
1,430 |
$87K |
| D0210 |
Intraoral - complete series of radiographic images |
1,185 |
1,179 |
$53K |
| D1120 |
Prophylaxis - child |
1,252 |
1,241 |
$49K |
| D1110 |
Prophylaxis - adult |
492 |
491 |
$36K |
| D9430 |
|
969 |
884 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
517 |
258 |
$28K |
| D0274 |
Bitewings - four radiographic images |
1,250 |
1,245 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,808 |
1,802 |
$21K |
| D4341 |
|
265 |
80 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,412 |
2,052 |
$18K |
| D4910 |
|
224 |
224 |
$17K |
| D0350 |
|
1,852 |
1,107 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
191 |
110 |
$15K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
116 |
54 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
753 |
721 |
$9K |
| D1351 |
Sealant - per tooth |
202 |
55 |
$6K |
| D2330 |
|
54 |
24 |
$4K |
| D0272 |
Bitewings - two radiographic images |
113 |
113 |
$1K |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$157.50 |