| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
529 |
465 |
$341K |
| D1110 |
Prophylaxis - adult |
5,634 |
5,620 |
$313K |
| D0120 |
Periodic oral evaluation - established patient |
6,212 |
6,198 |
$171K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,643 |
1,423 |
$156K |
| D0274 |
Bitewings - four radiographic images |
4,512 |
4,505 |
$125K |
| D7140 |
Extraction, erupted tooth or exposed root |
968 |
768 |
$74K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,137 |
982 |
$74K |
| D1120 |
Prophylaxis - child |
1,373 |
1,366 |
$58K |
| D0210 |
Intraoral - complete series of radiographic images |
1,815 |
1,806 |
$45K |
| D0272 |
Bitewings - two radiographic images |
2,203 |
2,192 |
$37K |
| D0330 |
Panoramic radiographic image |
947 |
945 |
$30K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
219 |
197 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,269 |
1,263 |
$18K |
| D5110 |
|
12 |
12 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
376 |
371 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
559 |
556 |
$5K |
| D2330 |
|
40 |
38 |
$3K |
| D2954 |
|
12 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
162 |
161 |
$2K |
| D2331 |
|
21 |
14 |
$2K |