| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
418 |
285 |
$197K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,172 |
576 |
$112K |
| D4910 |
|
1,191 |
1,183 |
$91K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,219 |
500 |
$79K |
| D0120 |
Periodic oral evaluation - established patient |
939 |
930 |
$66K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
716 |
713 |
$47K |
| D2954 |
|
332 |
230 |
$35K |
| D1110 |
Prophylaxis - adult |
407 |
402 |
$35K |
| D2330 |
|
473 |
197 |
$34K |
| D0350 |
|
3,330 |
1,007 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,806 |
1,548 |
$32K |
| D1120 |
Prophylaxis - child |
693 |
684 |
$30K |
| D0274 |
Bitewings - four radiographic images |
1,076 |
1,070 |
$22K |
| D2331 |
|
237 |
55 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,127 |
1,114 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
257 |
257 |
$12K |
| D9430 |
|
380 |
345 |
$12K |
| D4341 |
|
161 |
43 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
134 |
75 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
636 |
540 |
$8K |
| D4342 |
|
40 |
12 |
$2K |
| D3221 |
|
13 |
12 |
$819.00 |
| D1330 |
|
13 |
12 |
$0.00 |