| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
525 |
296 |
$246K |
| D0120 |
Periodic oral evaluation - established patient |
2,024 |
2,013 |
$110K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,128 |
1,124 |
$72K |
| D1120 |
Prophylaxis - child |
1,471 |
1,465 |
$59K |
| D0210 |
Intraoral - complete series of radiographic images |
752 |
752 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,647 |
2,556 |
$30K |
| D0274 |
Bitewings - four radiographic images |
1,427 |
1,417 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
392 |
261 |
$26K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
32 |
24 |
$15K |
| D2954 |
|
139 |
85 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,029 |
1,025 |
$12K |
| D4910 |
|
98 |
98 |
$8K |
| D0350 |
|
630 |
298 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
104 |
68 |
$6K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
56 |
38 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
43 |
16 |
$2K |
| D1110 |
Prophylaxis - adult |
18 |
18 |
$2K |
| D2140 |
|
29 |
13 |
$2K |
| D0272 |
Bitewings - two radiographic images |
127 |
127 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$1K |
| D9430 |
|
14 |
13 |
$448.00 |