| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
631 |
393 |
$361K |
| D1110 |
Prophylaxis - adult |
5,385 |
5,327 |
$282K |
| D0274 |
Bitewings - four radiographic images |
4,944 |
4,886 |
$168K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,069 |
533 |
$137K |
| D0120 |
Periodic oral evaluation - established patient |
5,412 |
5,362 |
$125K |
| D0140 |
Limited oral evaluation - problem focused |
3,244 |
3,025 |
$122K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,233 |
744 |
$106K |
| D9450 |
|
4,798 |
4,090 |
$95K |
| D0330 |
Panoramic radiographic image |
1,882 |
1,861 |
$84K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,382 |
1,366 |
$58K |
| D2950 |
|
352 |
223 |
$55K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,906 |
1,899 |
$55K |
| D1120 |
Prophylaxis - child |
1,056 |
1,055 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
697 |
466 |
$52K |
| D0220 |
Intraoral - periapical first radiographic image |
2,505 |
2,309 |
$36K |
| D9110 |
|
664 |
619 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
184 |
132 |
$12K |
| D2394 |
|
48 |
31 |
$6K |
| D0180 |
|
129 |
129 |
$6K |
| D0272 |
Bitewings - two radiographic images |
192 |
191 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
259 |
167 |
$3K |
| D2750 |
|
17 |
12 |
$1K |
| D1351 |
Sealant - per tooth |
41 |
12 |
$1K |