| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
998 |
569 |
$463K |
| D0120 |
Periodic oral evaluation - established patient |
3,479 |
3,430 |
$141K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,744 |
1,730 |
$97K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,550 |
5,281 |
$93K |
| D2954 |
|
778 |
461 |
$77K |
| D4341 |
|
1,032 |
286 |
$68K |
| D0274 |
Bitewings - four radiographic images |
3,608 |
3,576 |
$67K |
| D1120 |
Prophylaxis - child |
2,214 |
2,180 |
$66K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
853 |
393 |
$51K |
| D0210 |
Intraoral - complete series of radiographic images |
1,105 |
1,100 |
$47K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
101 |
82 |
$46K |
| D9430 |
|
1,593 |
1,481 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
478 |
271 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,293 |
2,260 |
$24K |
| D2160 |
|
262 |
147 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
224 |
114 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,219 |
1,199 |
$12K |
| D4910 |
|
102 |
102 |
$7K |
| D1351 |
Sealant - per tooth |
226 |
61 |
$5K |
| D3310 |
|
18 |
12 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
42 |
29 |
$5K |
| D2140 |
|
75 |
37 |
$4K |
| D7240 |
Removal of impacted tooth - completely bony |
31 |
12 |
$4K |
| D1110 |
Prophylaxis - adult |
46 |
46 |
$3K |
| D0272 |
Bitewings - two radiographic images |
347 |
344 |
$3K |
| D0330 |
Panoramic radiographic image |
110 |
108 |
$3K |
| D1310 |
|
299 |
288 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$950.40 |
| D0350 |
|
35 |
28 |
$402.00 |
| D1330 |
|
375 |
360 |
$0.00 |