| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
1,368 |
932 |
$650K |
| D1110 |
Prophylaxis - adult |
3,935 |
3,920 |
$341K |
| D0120 |
Periodic oral evaluation - established patient |
4,745 |
4,729 |
$262K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,402 |
2,398 |
$150K |
| D0210 |
Intraoral - complete series of radiographic images |
2,322 |
2,314 |
$108K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
724 |
473 |
$86K |
| D0274 |
Bitewings - four radiographic images |
3,257 |
3,245 |
$69K |
| D2954 |
|
577 |
458 |
$60K |
| D0220 |
Intraoral - periapical first radiographic image |
4,557 |
4,379 |
$54K |
| D9430 |
|
1,617 |
1,588 |
$52K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
652 |
506 |
$51K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12,711 |
5,278 |
$51K |
| D1120 |
Prophylaxis - child |
1,262 |
1,259 |
$51K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
600 |
481 |
$40K |
| D3320 |
|
39 |
36 |
$14K |
| D2335 |
|
19 |
12 |
$2K |
| D1206 |
Topical application of fluoride varnish |
198 |
197 |
$2K |
| D4910 |
|
26 |
26 |
$2K |
| D2920 |
|
46 |
40 |
$2K |
| D2394 |
|
17 |
12 |
$1K |
| D0350 |
|
149 |
100 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
13 |
$982.80 |