| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
433 |
350 |
$205K |
| D0120 |
Periodic oral evaluation - established patient |
2,262 |
2,244 |
$134K |
| D1120 |
Prophylaxis - child |
1,741 |
1,729 |
$71K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,100 |
1,092 |
$68K |
| D1110 |
Prophylaxis - adult |
739 |
730 |
$65K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
824 |
579 |
$54K |
| D0210 |
Intraoral - complete series of radiographic images |
881 |
877 |
$40K |
| D0274 |
Bitewings - four radiographic images |
1,852 |
1,832 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,687 |
2,606 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,686 |
1,672 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,584 |
1,530 |
$19K |
| D9430 |
|
448 |
435 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
126 |
85 |
$7K |
| D1351 |
Sealant - per tooth |
135 |
28 |
$3K |
| D1206 |
Topical application of fluoride varnish |
139 |
139 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
28 |
26 |
$2K |
| D4341 |
|
43 |
12 |
$2K |
| D4910 |
|
12 |
12 |
$847.00 |