| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
798 |
636 |
$378K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,644 |
3,631 |
$240K |
| D1110 |
Prophylaxis - adult |
2,666 |
2,658 |
$229K |
| D0120 |
Periodic oral evaluation - established patient |
2,852 |
2,838 |
$214K |
| D4341 |
|
2,045 |
569 |
$143K |
| D0230 |
Intraoral - periapical each additional radiographic image |
28,231 |
6,744 |
$117K |
| D2740 |
Crown - porcelain/ceramic |
243 |
194 |
$115K |
| D4910 |
|
1,426 |
1,422 |
$109K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,431 |
958 |
$96K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
190 |
177 |
$88K |
| D0274 |
Bitewings - four radiographic images |
4,150 |
4,130 |
$85K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,091 |
6,059 |
$76K |
| D1120 |
Prophylaxis - child |
1,644 |
1,640 |
$72K |
| D0210 |
Intraoral - complete series of radiographic images |
1,239 |
1,238 |
$58K |
| D2954 |
|
532 |
438 |
$55K |
| D9430 |
|
1,661 |
1,626 |
$53K |
| D0350 |
|
3,845 |
1,140 |
$35K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
357 |
295 |
$28K |
| D1351 |
Sealant - per tooth |
654 |
149 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
384 |
264 |
$21K |
| D1320 |
|
602 |
601 |
$10K |
| D3320 |
|
26 |
25 |
$10K |
| D4342 |
|
177 |
71 |
$7K |
| D2920 |
|
135 |
103 |
$6K |
| D0330 |
Panoramic radiographic image |
197 |
197 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
13 |
$975.80 |
| D9993 |
|
12 |
12 |
$650.00 |
| D0272 |
Bitewings - two radiographic images |
49 |
49 |
$552.00 |
| D1310 |
|
12 |
12 |
$460.00 |
| D0601 |
|
12 |
12 |
$150.00 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$146.00 |
| D1999 |
|
50 |
50 |
$0.00 |
| D1330 |
|
32 |
32 |
$0.00 |