| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
1,324 |
1,039 |
$245K |
| D1110 |
Prophylaxis - adult |
9,413 |
9,309 |
$100K |
| D0120 |
Periodic oral evaluation - established patient |
7,934 |
7,849 |
$76K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,050 |
4,984 |
$61K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,270 |
1,663 |
$59K |
| D0274 |
Bitewings - four radiographic images |
8,114 |
8,039 |
$47K |
| D1351 |
Sealant - per tooth |
4,660 |
602 |
$37K |
| D2954 |
|
992 |
796 |
$34K |
| D0220 |
Intraoral - periapical first radiographic image |
12,023 |
11,842 |
$30K |
| D1120 |
Prophylaxis - child |
3,006 |
2,981 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,045 |
525 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,744 |
3,710 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,495 |
11,262 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
704 |
400 |
$15K |
| D4249 |
|
469 |
230 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
1,033 |
1,023 |
$9K |
| D0272 |
Bitewings - two radiographic images |
1,611 |
1,600 |
$7K |
| D1206 |
Topical application of fluoride varnish |
487 |
487 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
204 |
116 |
$6K |
| D3320 |
|
56 |
46 |
$6K |
| D0330 |
Panoramic radiographic image |
576 |
536 |
$4K |
| D4341 |
|
175 |
54 |
$4K |
| D2332 |
|
42 |
24 |
$1K |
| D2331 |
|
21 |
15 |
$627.00 |
| D0601 |
|
78 |
78 |
$460.00 |