| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
114 |
75 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,230 |
1,225 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,962 |
1,942 |
$34K |
| D1120 |
Prophylaxis - child |
1,762 |
1,755 |
$31K |
| D1110 |
Prophylaxis - adult |
338 |
338 |
$22K |
| D7240 |
Removal of impacted tooth - completely bony |
92 |
39 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
3,666 |
2,893 |
$12K |
| D1206 |
Topical application of fluoride varnish |
1,767 |
1,760 |
$11K |
| D0330 |
Panoramic radiographic image |
464 |
464 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
531 |
525 |
$11K |
| D0274 |
Bitewings - four radiographic images |
1,707 |
1,698 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,842 |
2,394 |
$10K |
| D9110 |
|
660 |
638 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
66 |
57 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
182 |
182 |
$3K |
| D1310 |
|
144 |
143 |
$3K |
| D9430 |
|
60 |
59 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
13 |
$1K |
| D0270 |
|
324 |
316 |
$862.23 |
| D1320 |
|
30 |
30 |
$385.28 |
| D1330 |
|
771 |
713 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
31 |
27 |
$0.00 |
| D9993 |
|
42 |
42 |
$0.00 |