| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
1,027 |
582 |
$489K |
| D4910 |
|
3,009 |
2,987 |
$272K |
| D1110 |
Prophylaxis - adult |
2,859 |
2,846 |
$217K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,186 |
3,137 |
$184K |
| D4341 |
|
2,592 |
707 |
$177K |
| D0120 |
Periodic oral evaluation - established patient |
2,510 |
2,468 |
$150K |
| D0210 |
Intraoral - complete series of radiographic images |
2,292 |
2,260 |
$88K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,190 |
537 |
$81K |
| D1120 |
Prophylaxis - child |
1,786 |
1,753 |
$79K |
| D1206 |
Topical application of fluoride varnish |
3,054 |
3,026 |
$60K |
| D2954 |
|
519 |
350 |
$56K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,817 |
2,726 |
$44K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,215 |
2,190 |
$41K |
| D0274 |
Bitewings - four radiographic images |
1,717 |
1,698 |
$33K |
| D9999 |
Unspecified adjunctive procedure, by report |
210 |
196 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
455 |
271 |
$25K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
307 |
158 |
$25K |
| D1351 |
Sealant - per tooth |
676 |
161 |
$25K |
| D4342 |
|
444 |
148 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,634 |
1,526 |
$15K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
110 |
72 |
$13K |
| D1310 |
|
221 |
220 |
$10K |
| D2330 |
|
91 |
58 |
$7K |
| D9430 |
|
126 |
124 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
26 |
24 |
$2K |
| D0350 |
|
223 |
112 |
$2K |
| D1999 |
|
257 |
243 |
$2K |
| D1320 |
|
66 |
66 |
$952.50 |
| D0601 |
|
44 |
44 |
$477.00 |
| D0272 |
Bitewings - two radiographic images |
17 |
17 |
$207.00 |
| D0602 |
|
14 |
14 |
$182.00 |