| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
666 |
384 |
$319K |
| D0120 |
Periodic oral evaluation - established patient |
1,363 |
1,354 |
$56K |
| D1110 |
Prophylaxis - adult |
1,269 |
1,252 |
$44K |
| D0210 |
Intraoral - complete series of radiographic images |
721 |
702 |
$28K |
| D2954 |
|
338 |
195 |
$27K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
54 |
41 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
950 |
935 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
378 |
217 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
434 |
234 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
670 |
648 |
$15K |
| D1120 |
Prophylaxis - child |
395 |
393 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,912 |
1,713 |
$8K |
| D0274 |
Bitewings - four radiographic images |
412 |
412 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
112 |
39 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
251 |
249 |
$3K |
| D1351 |
Sealant - per tooth |
124 |
15 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
631 |
465 |
$3K |
| D1206 |
Topical application of fluoride varnish |
71 |
71 |
$1K |
| D0603 |
|
108 |
108 |
$1K |
| D2950 |
|
27 |
12 |
$920.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$345.00 |