| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
944 |
638 |
$448K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,509 |
1,500 |
$96K |
| D1110 |
Prophylaxis - adult |
931 |
923 |
$77K |
| D0120 |
Periodic oral evaluation - established patient |
1,273 |
1,258 |
$75K |
| D0210 |
Intraoral - complete series of radiographic images |
1,142 |
1,135 |
$53K |
| D4341 |
|
648 |
170 |
$45K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
675 |
454 |
$45K |
| D2954 |
|
354 |
271 |
$37K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
311 |
182 |
$35K |
| D2952 |
|
314 |
229 |
$33K |
| D4910 |
|
332 |
332 |
$25K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
37 |
36 |
$17K |
| D9430 |
|
517 |
510 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,031 |
1,025 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
263 |
139 |
$14K |
| D3320 |
|
33 |
28 |
$12K |
| D3221 |
|
122 |
101 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
448 |
432 |
$5K |
| D9951 |
|
149 |
82 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
60 |
41 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
902 |
269 |
$4K |
| D5520 |
|
26 |
13 |
$2K |
| D2331 |
|
19 |
14 |
$2K |
| D2920 |
|
25 |
22 |
$1K |
| D5410 |
|
31 |
28 |
$980.00 |
| D5411 |
|
25 |
25 |
$875.00 |
| D1206 |
Topical application of fluoride varnish |
52 |
52 |
$842.00 |
| D5510 |
|
12 |
12 |
$560.00 |
| D5422 |
|
14 |
14 |
$490.00 |