| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
344 |
290 |
$163K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,070 |
1,064 |
$71K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,053 |
706 |
$70K |
| D1110 |
Prophylaxis - adult |
665 |
662 |
$58K |
| D0210 |
Intraoral - complete series of radiographic images |
808 |
806 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
466 |
464 |
$38K |
| D4910 |
|
468 |
463 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
577 |
399 |
$31K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
264 |
117 |
$31K |
| D4341 |
|
241 |
78 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,063 |
705 |
$17K |
| D0350 |
|
1,679 |
848 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
154 |
119 |
$12K |
| D1206 |
Topical application of fluoride varnish |
616 |
615 |
$11K |
| D1120 |
Prophylaxis - child |
218 |
218 |
$10K |
| D0274 |
Bitewings - four radiographic images |
443 |
442 |
$9K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
13 |
12 |
$6K |
| D2954 |
|
57 |
55 |
$6K |
| D2330 |
|
49 |
29 |
$4K |
| D4342 |
|
77 |
25 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
222 |
222 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
68 |
67 |
$816.00 |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$480.00 |
| D9430 |
|
13 |
13 |
$416.00 |
| D1999 |
|
28 |
23 |
$0.00 |