| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
649 |
603 |
$405K |
| D1110 |
Prophylaxis - adult |
6,703 |
6,702 |
$364K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,786 |
2,316 |
$259K |
| D0120 |
Periodic oral evaluation - established patient |
7,822 |
7,819 |
$212K |
| D0274 |
Bitewings - four radiographic images |
5,908 |
5,908 |
$162K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,552 |
1,182 |
$111K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,521 |
1,272 |
$92K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
835 |
722 |
$88K |
| D0210 |
Intraoral - complete series of radiographic images |
2,674 |
2,657 |
$60K |
| D0330 |
Panoramic radiographic image |
1,609 |
1,608 |
$49K |
| D1120 |
Prophylaxis - child |
884 |
884 |
$38K |
| D0272 |
Bitewings - two radiographic images |
1,644 |
1,644 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,802 |
1,802 |
$25K |
| D2331 |
|
273 |
230 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
1,888 |
1,879 |
$25K |
| D2954 |
|
87 |
83 |
$13K |
| D2330 |
|
145 |
115 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
156 |
156 |
$2K |
| D2332 |
|
15 |
13 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
42 |
42 |
$572.00 |