| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
285 |
210 |
$136K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,999 |
1,995 |
$132K |
| D1110 |
Prophylaxis - adult |
1,126 |
1,123 |
$97K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,400 |
891 |
$92K |
| D4341 |
|
1,285 |
548 |
$89K |
| D0120 |
Periodic oral evaluation - established patient |
1,025 |
1,023 |
$74K |
| D0210 |
Intraoral - complete series of radiographic images |
1,469 |
1,466 |
$69K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,131 |
584 |
$64K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
979 |
599 |
$53K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
511 |
399 |
$40K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,186 |
1,772 |
$39K |
| D1120 |
Prophylaxis - child |
899 |
897 |
$37K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
546 |
327 |
$37K |
| D0274 |
Bitewings - four radiographic images |
1,295 |
1,289 |
$26K |
| D2160 |
|
282 |
210 |
$22K |
| D2330 |
|
271 |
167 |
$21K |
| D2332 |
|
131 |
93 |
$11K |
| D2331 |
|
92 |
67 |
$7K |
| D2140 |
|
96 |
69 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
292 |
292 |
$3K |
| D4910 |
|
24 |
24 |
$2K |
| D4342 |
|
21 |
12 |
$882.00 |
| D9110 |
|
12 |
12 |
$756.00 |
| D0220 |
Intraoral - periapical first radiographic image |
44 |
43 |
$528.00 |