| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
514 |
277 |
$244K |
| D0120 |
Periodic oral evaluation - established patient |
1,210 |
1,199 |
$72K |
| D2954 |
|
676 |
363 |
$71K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
695 |
687 |
$43K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,433 |
2,100 |
$35K |
| D1120 |
Prophylaxis - child |
820 |
810 |
$31K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
51 |
41 |
$24K |
| D0274 |
Bitewings - four radiographic images |
744 |
736 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
319 |
319 |
$15K |
| D8670 |
Periodic orthodontic treatment visit |
51 |
51 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
947 |
937 |
$10K |
| D3320 |
|
17 |
14 |
$6K |
| D4910 |
|
64 |
64 |
$5K |
| D9430 |
|
99 |
93 |
$3K |
| D4341 |
|
36 |
13 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
12 |
$1K |
| D0350 |
|
113 |
67 |
$1K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$990.00 |
| D0272 |
Bitewings - two radiographic images |
55 |
55 |
$610.00 |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$450.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$420.00 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$216.00 |