| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
411 |
341 |
$83K |
| D1110 |
Prophylaxis - adult |
4,662 |
4,622 |
$49K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,035 |
1,399 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
4,596 |
4,556 |
$47K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,566 |
934 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,143 |
2,138 |
$26K |
| D1120 |
Prophylaxis - child |
1,761 |
1,755 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
1,258 |
1,257 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
1,359 |
1,315 |
$16K |
| D0274 |
Bitewings - four radiographic images |
2,712 |
2,688 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
452 |
331 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
4,929 |
4,855 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,838 |
1,833 |
$9K |
| D2954 |
|
237 |
202 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
486 |
237 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,326 |
4,274 |
$7K |
| D1351 |
Sealant - per tooth |
289 |
43 |
$3K |
| D2335 |
|
65 |
37 |
$2K |
| D2332 |
|
80 |
49 |
$2K |
| D2330 |
|
67 |
40 |
$1K |
| D2394 |
|
19 |
16 |
$605.00 |
| D0272 |
Bitewings - two radiographic images |
103 |
103 |
$315.00 |
| D2331 |
|
15 |
12 |
$295.00 |
| D0603 |
|
20 |
20 |
$120.00 |