| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
302 |
260 |
$143K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,087 |
575 |
$125K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,765 |
1,759 |
$111K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,216 |
714 |
$80K |
| D1110 |
Prophylaxis - adult |
890 |
888 |
$79K |
| D0210 |
Intraoral - complete series of radiographic images |
1,652 |
1,645 |
$77K |
| D0120 |
Periodic oral evaluation - established patient |
1,039 |
1,039 |
$74K |
| D4341 |
|
864 |
242 |
$60K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,122 |
592 |
$59K |
| D4910 |
|
680 |
680 |
$52K |
| D0350 |
|
4,617 |
1,957 |
$45K |
| D1120 |
Prophylaxis - child |
982 |
982 |
$43K |
| D9430 |
|
1,072 |
1,027 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,004 |
1,350 |
$30K |
| D1206 |
Topical application of fluoride varnish |
1,772 |
1,768 |
$29K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
56 |
54 |
$26K |
| D2952 |
|
204 |
174 |
$21K |
| D0274 |
Bitewings - four radiographic images |
666 |
666 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,044 |
1,011 |
$12K |
| D1351 |
Sealant - per tooth |
146 |
39 |
$6K |
| D4342 |
|
40 |
15 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
16 |
$2K |
| D0272 |
Bitewings - two radiographic images |
72 |
72 |
$858.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
27 |
27 |
$296.00 |