| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
859 |
620 |
$336K |
| D1110 |
Prophylaxis - adult |
4,602 |
4,602 |
$165K |
| D0120 |
Periodic oral evaluation - established patient |
6,741 |
6,739 |
$131K |
| D2954 |
|
729 |
564 |
$69K |
| D0274 |
Bitewings - four radiographic images |
3,342 |
3,342 |
$61K |
| D0220 |
Intraoral - periapical first radiographic image |
6,059 |
6,025 |
$55K |
| D1120 |
Prophylaxis - child |
1,643 |
1,642 |
$50K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,030 |
5,021 |
$49K |
| D0330 |
Panoramic radiographic image |
1,214 |
1,214 |
$29K |
| D0210 |
Intraoral - complete series of radiographic images |
2,095 |
2,088 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,810 |
1,810 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
310 |
247 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
434 |
282 |
$15K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
55 |
46 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
578 |
578 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
78 |
68 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
57 |
45 |
$2K |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$153.62 |