| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
549 |
360 |
$266K |
| D0120 |
Periodic oral evaluation - established patient |
4,334 |
4,279 |
$202K |
| D4341 |
|
1,784 |
528 |
$153K |
| D0230 |
Intraoral - periapical each additional radiographic image |
34,564 |
6,684 |
$141K |
| D1120 |
Prophylaxis - child |
3,522 |
3,496 |
$122K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,895 |
1,858 |
$100K |
| D4381 |
|
607 |
156 |
$86K |
| D0272 |
Bitewings - two radiographic images |
5,413 |
5,363 |
$60K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,854 |
3,827 |
$43K |
| D5214 |
|
36 |
36 |
$40K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
292 |
137 |
$39K |
| D1351 |
Sealant - per tooth |
1,643 |
468 |
$37K |
| D2140 |
|
605 |
225 |
$33K |
| D1110 |
Prophylaxis - adult |
344 |
344 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
491 |
268 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
307 |
280 |
$21K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
258 |
139 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
268 |
127 |
$15K |
| D5213 |
|
13 |
13 |
$15K |
| D8670 |
Periodic orthodontic treatment visit |
39 |
38 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
772 |
747 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
155 |
151 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
27 |
13 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
41 |
26 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
27 |
13 |
$3K |
| D4342 |
|
33 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
26 |
25 |
$750.00 |