| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
749 |
546 |
$356K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,577 |
1,569 |
$102K |
| D0120 |
Periodic oral evaluation - established patient |
1,260 |
1,252 |
$88K |
| D0210 |
Intraoral - complete series of radiographic images |
1,496 |
1,488 |
$71K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,053 |
631 |
$71K |
| D1120 |
Prophylaxis - child |
1,180 |
1,170 |
$50K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
101 |
91 |
$47K |
| D4910 |
|
593 |
592 |
$45K |
| D2954 |
|
404 |
327 |
$42K |
| D1110 |
Prophylaxis - adult |
440 |
439 |
$39K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
663 |
410 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,009 |
1,687 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,100 |
2,089 |
$27K |
| D4341 |
|
343 |
114 |
$24K |
| D9430 |
|
678 |
659 |
$22K |
| D0274 |
Bitewings - four radiographic images |
982 |
977 |
$21K |
| D0350 |
|
1,165 |
619 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
82 |
55 |
$7K |
| D3320 |
|
13 |
12 |
$5K |
| D7230 |
|
24 |
12 |
$5K |
| D7240 |
Removal of impacted tooth - completely bony |
18 |
12 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
315 |
299 |
$4K |
| D2140 |
|
72 |
28 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
52 |
29 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
33 |
18 |
$2K |
| D1351 |
Sealant - per tooth |
91 |
43 |
$2K |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$810.00 |
| D1310 |
|
12 |
12 |
$552.00 |
| D0272 |
Bitewings - two radiographic images |
47 |
47 |
$445.00 |
| D0603 |
|
12 |
12 |
$180.00 |
| D0140 |
Limited oral evaluation - problem focused |
26 |
25 |
$0.00 |