| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
521 |
411 |
$248K |
| D1110 |
Prophylaxis - adult |
2,178 |
2,175 |
$194K |
| D0120 |
Periodic oral evaluation - established patient |
2,503 |
2,498 |
$181K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,958 |
1,958 |
$129K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,705 |
1,087 |
$114K |
| D4910 |
|
862 |
857 |
$66K |
| D0230 |
Intraoral - periapical each additional radiographic image |
16,151 |
4,624 |
$65K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
719 |
534 |
$57K |
| D0274 |
Bitewings - four radiographic images |
2,059 |
2,054 |
$44K |
| D0210 |
Intraoral - complete series of radiographic images |
712 |
712 |
$34K |
| D1120 |
Prophylaxis - child |
571 |
570 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
2,015 |
1,964 |
$24K |
| D2954 |
|
226 |
195 |
$24K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
42 |
39 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
254 |
112 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
244 |
179 |
$13K |
| D9430 |
|
328 |
327 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
548 |
547 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
39 |
28 |
$5K |
| D0350 |
|
450 |
283 |
$4K |
| D2394 |
|
32 |
28 |
$3K |
| D0240 |
|
81 |
52 |
$840.00 |