| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
782 |
535 |
$372K |
| D4910 |
|
3,638 |
3,610 |
$279K |
| D1110 |
Prophylaxis - adult |
1,502 |
1,496 |
$134K |
| D0120 |
Periodic oral evaluation - established patient |
1,599 |
1,586 |
$112K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,351 |
861 |
$108K |
| D4341 |
|
1,457 |
417 |
$102K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,459 |
890 |
$98K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,186 |
1,184 |
$78K |
| D0210 |
Intraoral - complete series of radiographic images |
1,142 |
1,139 |
$55K |
| D2954 |
|
498 |
381 |
$52K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,421 |
1,837 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,078 |
2,067 |
$30K |
| D4342 |
|
508 |
157 |
$21K |
| D0274 |
Bitewings - four radiographic images |
1,007 |
1,002 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
279 |
199 |
$15K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
94 |
60 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
755 |
742 |
$9K |
| D2394 |
|
48 |
41 |
$4K |
| D0350 |
|
376 |
211 |
$3K |
| D1206 |
Topical application of fluoride varnish |
110 |
110 |
$2K |
| D2330 |
|
20 |
12 |
$2K |
| D1120 |
Prophylaxis - child |
24 |
24 |
$1K |
| D9430 |
|
24 |
24 |
$768.00 |