| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
558 |
351 |
$262K |
| D4910 |
|
3,002 |
2,987 |
$235K |
| D0120 |
Periodic oral evaluation - established patient |
1,514 |
1,496 |
$88K |
| D4341 |
|
1,262 |
343 |
$87K |
| D1110 |
Prophylaxis - adult |
871 |
862 |
$75K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,049 |
1,040 |
$68K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
842 |
436 |
$55K |
| D2952 |
|
427 |
276 |
$45K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,196 |
2,063 |
$44K |
| D0210 |
Intraoral - complete series of radiographic images |
816 |
816 |
$37K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
439 |
258 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,952 |
1,933 |
$32K |
| D0274 |
Bitewings - four radiographic images |
1,450 |
1,435 |
$28K |
| D1120 |
Prophylaxis - child |
440 |
438 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
216 |
108 |
$11K |
| D9110 |
|
165 |
131 |
$10K |
| D0350 |
|
402 |
159 |
$4K |
| D4342 |
|
94 |
29 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
270 |
264 |
$3K |
| D1206 |
Topical application of fluoride varnish |
186 |
184 |
$3K |
| D9430 |
|
36 |
36 |
$1K |
| D1351 |
Sealant - per tooth |
55 |
14 |
$975.00 |