| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
402 |
317 |
$174K |
| D2750 |
|
377 |
310 |
$163K |
| D1110 |
Prophylaxis - adult |
3,796 |
3,754 |
$85K |
| D0120 |
Periodic oral evaluation - established patient |
3,314 |
3,279 |
$74K |
| D0140 |
Limited oral evaluation - problem focused |
3,188 |
3,080 |
$70K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,300 |
833 |
$57K |
| D2954 |
|
556 |
462 |
$46K |
| D0274 |
Bitewings - four radiographic images |
2,854 |
2,824 |
$39K |
| D2740 |
Crown - porcelain/ceramic |
79 |
59 |
$39K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
79 |
73 |
$32K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
486 |
270 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
759 |
491 |
$29K |
| D0330 |
Panoramic radiographic image |
1,075 |
1,062 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
6,226 |
5,953 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,111 |
1,100 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,186 |
4,528 |
$22K |
| D1120 |
Prophylaxis - child |
615 |
615 |
$16K |
| D8670 |
Periodic orthodontic treatment visit |
342 |
285 |
$15K |
| D1206 |
Topical application of fluoride varnish |
610 |
599 |
$9K |
| D3320 |
|
13 |
12 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
255 |
251 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
90 |
90 |
$3K |
| D0272 |
Bitewings - two radiographic images |
311 |
311 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
30 |
25 |
$1K |
| D1351 |
Sealant - per tooth |
91 |
12 |
$1K |
| D9310 |
|
54 |
52 |
$528.00 |
| D4346 |
|
12 |
12 |
$415.00 |
| D1999 |
|
15 |
14 |
$0.00 |