| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
1,755 |
1,432 |
$709K |
| D1110 |
Prophylaxis - adult |
16,582 |
16,576 |
$628K |
| D0120 |
Periodic oral evaluation - established patient |
18,358 |
18,346 |
$362K |
| D0230 |
Intraoral - periapical each additional radiographic image |
16,377 |
16,360 |
$212K |
| D0210 |
Intraoral - complete series of radiographic images |
10,708 |
10,684 |
$156K |
| D0220 |
Intraoral - periapical first radiographic image |
15,523 |
15,491 |
$146K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,067 |
926 |
$68K |
| D2954 |
|
566 |
529 |
$57K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,239 |
1,019 |
$43K |
| D0274 |
Bitewings - four radiographic images |
2,060 |
2,059 |
$43K |
| D4341 |
|
646 |
390 |
$33K |
| D0272 |
Bitewings - two radiographic images |
2,161 |
2,161 |
$25K |
| D1120 |
Prophylaxis - child |
711 |
711 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
371 |
316 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,454 |
1,454 |
$16K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
62 |
61 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
993 |
989 |
$10K |
| D0330 |
Panoramic radiographic image |
537 |
536 |
$9K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
92 |
83 |
$6K |
| D3320 |
|
14 |
14 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
30 |
28 |
$2K |
| D1206 |
Topical application of fluoride varnish |
40 |
40 |
$876.50 |