| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
1,209 |
562 |
$573K |
| D4910 |
|
2,933 |
2,921 |
$224K |
| D1110 |
Prophylaxis - adult |
2,325 |
2,299 |
$197K |
| D9430 |
|
4,294 |
3,776 |
$136K |
| D0120 |
Periodic oral evaluation - established patient |
2,270 |
2,251 |
$124K |
| D2952 |
|
1,105 |
565 |
$115K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,634 |
1,625 |
$101K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,530 |
995 |
$101K |
| D4341 |
|
1,156 |
334 |
$81K |
| D0210 |
Intraoral - complete series of radiographic images |
1,564 |
1,553 |
$73K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,895 |
2,877 |
$38K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
632 |
400 |
$34K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
376 |
298 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
1,781 |
1,732 |
$21K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
111 |
62 |
$13K |
| D1320 |
|
796 |
794 |
$12K |
| D2330 |
|
140 |
83 |
$10K |
| D0350 |
|
820 |
493 |
$8K |
| D4342 |
|
190 |
73 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,542 |
869 |
$7K |
| D3347 |
|
16 |
13 |
$6K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
12 |
12 |
$6K |
| D3221 |
|
56 |
49 |
$3K |
| D2331 |
|
33 |
15 |
$3K |
| D1120 |
Prophylaxis - child |
78 |
77 |
$2K |
| D2920 |
|
33 |
24 |
$1K |
| D5851 |
|
12 |
12 |
$840.00 |
| D5850 |
|
12 |
12 |
$770.00 |
| D9110 |
|
13 |
12 |
$756.00 |
| D5411 |
|
13 |
13 |
$455.00 |
| D5410 |
|
13 |
13 |
$455.00 |
| D1999 |
|
18 |
18 |
$0.00 |
| D1330 |
|
1,839 |
1,828 |
$0.00 |
| D1310 |
|
66 |
66 |
$0.00 |