| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
618 |
520 |
$390K |
| D1110 |
Prophylaxis - adult |
4,531 |
4,509 |
$228K |
| D0120 |
Periodic oral evaluation - established patient |
7,173 |
7,138 |
$201K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,926 |
1,234 |
$111K |
| D0140 |
Limited oral evaluation - problem focused |
1,927 |
1,888 |
$93K |
| D1120 |
Prophylaxis - child |
1,355 |
1,346 |
$69K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,252 |
828 |
$57K |
| D0210 |
Intraoral - complete series of radiographic images |
917 |
917 |
$47K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
627 |
460 |
$43K |
| D0220 |
Intraoral - periapical first radiographic image |
7,274 |
7,150 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,335 |
1,326 |
$34K |
| D0274 |
Bitewings - four radiographic images |
2,716 |
2,701 |
$33K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
308 |
200 |
$30K |
| D2954 |
|
268 |
230 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,701 |
5,646 |
$20K |
| D0272 |
Bitewings - two radiographic images |
1,168 |
1,160 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
155 |
72 |
$9K |
| D0330 |
Panoramic radiographic image |
397 |
387 |
$6K |
| D1351 |
Sealant - per tooth |
258 |
40 |
$6K |
| D2335 |
|
31 |
25 |
$3K |
| D2950 |
|
36 |
31 |
$2K |
| D2330 |
|
35 |
27 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
55 |
55 |
$2K |
| D1206 |
Topical application of fluoride varnish |
18 |
18 |
$646.92 |
| D1999 |
|
1,133 |
978 |
$0.00 |