| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2750 |
|
295 |
220 |
$82K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
182 |
141 |
$51K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,245 |
805 |
$39K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,315 |
744 |
$35K |
| D1110 |
Prophylaxis - adult |
1,714 |
1,714 |
$28K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
41 |
37 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,404 |
1,404 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
1,070 |
1,069 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
1,136 |
1,091 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
1,148 |
1,147 |
$16K |
| D2954 |
|
288 |
236 |
$12K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
172 |
102 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,415 |
1,412 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
2,524 |
2,425 |
$10K |
| D1120 |
Prophylaxis - child |
690 |
689 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
190 |
152 |
$7K |
| D0274 |
Bitewings - four radiographic images |
1,085 |
1,085 |
$7K |
| D3950 |
|
124 |
110 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,873 |
1,821 |
$4K |
| D2950 |
|
99 |
80 |
$4K |
| D2740 |
Crown - porcelain/ceramic |
16 |
16 |
$3K |
| D9310 |
|
82 |
81 |
$3K |
| D0330 |
Panoramic radiographic image |
80 |
80 |
$1K |
| D4341 |
|
32 |
12 |
$1K |
| D1351 |
Sealant - per tooth |
95 |
19 |
$993.00 |
| D0272 |
Bitewings - two radiographic images |
36 |
36 |
$122.50 |
| D0270 |
|
16 |
16 |
$33.50 |