| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
371 |
270 |
$175K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,141 |
575 |
$76K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
990 |
987 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
478 |
478 |
$38K |
| D1110 |
Prophylaxis - adult |
421 |
421 |
$37K |
| D0210 |
Intraoral - complete series of radiographic images |
774 |
771 |
$37K |
| D2954 |
|
300 |
220 |
$31K |
| D4341 |
|
369 |
98 |
$26K |
| D4910 |
|
334 |
334 |
$26K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
311 |
213 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,818 |
1,422 |
$20K |
| D0350 |
|
1,985 |
699 |
$19K |
| D1120 |
Prophylaxis - child |
360 |
356 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,193 |
1,188 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,101 |
1,019 |
$13K |
| D0274 |
Bitewings - four radiographic images |
417 |
417 |
$9K |
| D9430 |
|
270 |
268 |
$9K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
72 |
41 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
74 |
40 |
$4K |