| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
1,135 |
820 |
$539K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,417 |
3,406 |
$225K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,341 |
1,905 |
$220K |
| D4341 |
|
2,854 |
779 |
$200K |
| D4910 |
|
2,138 |
2,123 |
$163K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,297 |
516 |
$153K |
| D0210 |
Intraoral - complete series of radiographic images |
3,146 |
3,138 |
$149K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,633 |
1,425 |
$141K |
| D0120 |
Periodic oral evaluation - established patient |
1,825 |
1,820 |
$124K |
| D0350 |
|
7,011 |
2,812 |
$70K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
149 |
139 |
$67K |
| D1120 |
Prophylaxis - child |
1,562 |
1,560 |
$63K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,339 |
2,108 |
$48K |
| D1206 |
Topical application of fluoride varnish |
2,780 |
2,771 |
$41K |
| D1110 |
Prophylaxis - adult |
422 |
421 |
$37K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
438 |
321 |
$34K |
| D0274 |
Bitewings - four radiographic images |
1,633 |
1,630 |
$33K |
| D9430 |
|
935 |
896 |
$30K |
| D4342 |
|
544 |
176 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,009 |
991 |
$12K |
| D2740 |
Crown - porcelain/ceramic |
25 |
21 |
$12K |
| D2330 |
|
103 |
66 |
$8K |
| D2331 |
|
84 |
54 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
358 |
357 |
$5K |
| D3310 |
|
13 |
12 |
$4K |
| D1351 |
Sealant - per tooth |
127 |
29 |
$3K |
| D0272 |
Bitewings - two radiographic images |
40 |
40 |
$468.00 |
| D1999 |
|
63 |
53 |
$40.00 |
| D0180 |
|
30 |
30 |
$0.00 |
| D1330 |
|
13 |
13 |
$0.00 |