| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
614 |
413 |
$291K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,966 |
1,830 |
$215K |
| D1110 |
Prophylaxis - adult |
2,337 |
2,330 |
$202K |
| D0120 |
Periodic oral evaluation - established patient |
2,784 |
2,777 |
$164K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,946 |
1,096 |
$130K |
| D4341 |
|
1,219 |
362 |
$83K |
| D0230 |
Intraoral - periapical each additional radiographic image |
19,276 |
2,859 |
$83K |
| D2330 |
|
784 |
381 |
$59K |
| D4910 |
|
715 |
707 |
$55K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,102 |
4,087 |
$54K |
| D0210 |
Intraoral - complete series of radiographic images |
859 |
858 |
$41K |
| D1120 |
Prophylaxis - child |
891 |
889 |
$36K |
| D0350 |
|
3,394 |
1,504 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
464 |
463 |
$30K |
| D0272 |
Bitewings - two radiographic images |
1,039 |
1,038 |
$12K |
| D9110 |
|
162 |
160 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
103 |
63 |
$6K |
| D2954 |
|
34 |
27 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
273 |
267 |
$3K |
| D4342 |
|
45 |
17 |
$2K |
| D1351 |
Sealant - per tooth |
63 |
13 |
$1K |
| D9430 |
|
31 |
30 |
$992.00 |
| D0330 |
Panoramic radiographic image |
33 |
33 |
$990.00 |