| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
1,340 |
823 |
$633K |
| D1110 |
Prophylaxis - adult |
2,540 |
2,525 |
$225K |
| D0120 |
Periodic oral evaluation - established patient |
2,316 |
2,306 |
$158K |
| D4910 |
|
1,615 |
1,608 |
$123K |
| D2952 |
|
1,022 |
660 |
$107K |
| D0230 |
Intraoral - periapical each additional radiographic image |
19,923 |
4,367 |
$84K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,061 |
1,061 |
$69K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,184 |
4,154 |
$57K |
| D0274 |
Bitewings - four radiographic images |
2,197 |
2,190 |
$47K |
| D0210 |
Intraoral - complete series of radiographic images |
958 |
958 |
$45K |
| D4341 |
|
632 |
179 |
$44K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
70 |
62 |
$32K |
| D1320 |
|
1,191 |
1,180 |
$21K |
| D9430 |
|
630 |
615 |
$20K |
| D0350 |
|
1,636 |
678 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
175 |
98 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
205 |
108 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,011 |
989 |
$12K |
| D3320 |
|
30 |
24 |
$11K |
| D1120 |
Prophylaxis - child |
261 |
260 |
$10K |
| D2394 |
|
86 |
67 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
43 |
26 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
61 |
24 |
$3K |