| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
560 |
434 |
$328K |
| D1110 |
Prophylaxis - adult |
1,569 |
1,542 |
$74K |
| D0120 |
Periodic oral evaluation - established patient |
1,668 |
1,645 |
$46K |
| D0140 |
Limited oral evaluation - problem focused |
651 |
626 |
$30K |
| D1120 |
Prophylaxis - child |
470 |
465 |
$23K |
| D0330 |
Panoramic radiographic image |
508 |
500 |
$18K |
| D2950 |
|
292 |
233 |
$18K |
| D1206 |
Topical application of fluoride varnish |
525 |
520 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
340 |
240 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
250 |
177 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
181 |
180 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
299 |
293 |
$8K |
| D0274 |
Bitewings - four radiographic images |
572 |
564 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
704 |
678 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
37 |
18 |
$3K |
| D1351 |
Sealant - per tooth |
94 |
12 |
$2K |
| D0170 |
|
12 |
12 |
$594.00 |
| D0270 |
|
14 |
14 |
$77.00 |