| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
844 |
574 |
$401K |
| D0120 |
Periodic oral evaluation - established patient |
6,698 |
6,661 |
$384K |
| D1120 |
Prophylaxis - child |
5,330 |
5,291 |
$203K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,865 |
1,758 |
$190K |
| D0230 |
Intraoral - periapical each additional radiographic image |
45,696 |
8,672 |
$188K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,832 |
2,823 |
$179K |
| D1110 |
Prophylaxis - adult |
1,474 |
1,461 |
$125K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,174 |
1,271 |
$116K |
| D0274 |
Bitewings - four radiographic images |
4,778 |
4,746 |
$100K |
| D0210 |
Intraoral - complete series of radiographic images |
2,138 |
2,132 |
$100K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
187 |
168 |
$86K |
| D9430 |
|
2,736 |
2,616 |
$86K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,786 |
6,737 |
$84K |
| D4341 |
|
981 |
264 |
$66K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
868 |
536 |
$57K |
| D4910 |
|
692 |
687 |
$53K |
| D0220 |
Intraoral - periapical first radiographic image |
3,081 |
3,041 |
$36K |
| D2954 |
|
332 |
232 |
$35K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
210 |
135 |
$25K |
| D0350 |
|
2,279 |
941 |
$21K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
244 |
183 |
$19K |
| D1351 |
Sealant - per tooth |
312 |
79 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
122 |
66 |
$7K |
| D3320 |
|
13 |
12 |
$5K |
| D9110 |
|
62 |
62 |
$4K |
| D2140 |
|
47 |
26 |
$3K |
| D2330 |
|
28 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
116 |
115 |
$1K |
| D2332 |
|
17 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$390.00 |
| D1999 |
|
98 |
91 |
$0.00 |