| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
254 |
190 |
$121K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,369 |
1,365 |
$85K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,001 |
533 |
$67K |
| D0120 |
Periodic oral evaluation - established patient |
974 |
968 |
$63K |
| D1120 |
Prophylaxis - child |
1,103 |
1,090 |
$46K |
| D0210 |
Intraoral - complete series of radiographic images |
953 |
950 |
$44K |
| D9430 |
|
1,264 |
1,161 |
$40K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
731 |
365 |
$39K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,218 |
1,588 |
$30K |
| D0330 |
Panoramic radiographic image |
941 |
936 |
$27K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
159 |
62 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,523 |
1,356 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,308 |
1,295 |
$17K |
| D1110 |
Prophylaxis - adult |
195 |
195 |
$17K |
| D0274 |
Bitewings - four radiographic images |
821 |
815 |
$16K |
| D2954 |
|
76 |
61 |
$8K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
12 |
12 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
58 |
39 |
$5K |
| D4910 |
|
54 |
54 |
$4K |
| D1351 |
Sealant - per tooth |
103 |
27 |
$3K |
| D0272 |
Bitewings - two radiographic images |
41 |
38 |
$424.00 |