| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
741 |
503 |
$301K |
| D1110 |
Prophylaxis - adult |
6,496 |
6,381 |
$152K |
| D2740 |
Crown - porcelain/ceramic |
277 |
201 |
$129K |
| D0120 |
Periodic oral evaluation - established patient |
4,060 |
4,007 |
$93K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,426 |
3,349 |
$77K |
| D0210 |
Intraoral - complete series of radiographic images |
1,978 |
1,924 |
$68K |
| D0140 |
Limited oral evaluation - problem focused |
2,791 |
2,694 |
$67K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,351 |
854 |
$61K |
| D0330 |
Panoramic radiographic image |
2,152 |
2,104 |
$57K |
| D2954 |
|
662 |
464 |
$51K |
| D0274 |
Bitewings - four radiographic images |
2,957 |
2,901 |
$35K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
83 |
70 |
$31K |
| D8670 |
Periodic orthodontic treatment visit |
540 |
492 |
$26K |
| D1120 |
Prophylaxis - child |
842 |
833 |
$24K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
403 |
189 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
5,141 |
4,889 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
537 |
342 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,714 |
1,701 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,449 |
3,765 |
$14K |
| D1351 |
Sealant - per tooth |
452 |
41 |
$12K |
| D3320 |
|
32 |
25 |
$8K |
| D1206 |
Topical application of fluoride varnish |
437 |
431 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
79 |
54 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
42 |
28 |
$2K |
| D2950 |
|
37 |
24 |
$2K |
| D4341 |
|
32 |
12 |
$1K |
| D9920 |
|
70 |
66 |
$1K |
| D0602 |
|
392 |
390 |
$1K |
| D0603 |
|
150 |
147 |
$870.00 |
| D4346 |
|
15 |
14 |
$490.00 |
| D0272 |
Bitewings - two radiographic images |
55 |
54 |
$385.00 |
| D9110 |
|
15 |
14 |
$140.00 |
| D0601 |
|
28 |
28 |
$130.00 |
| D9310 |
|
12 |
12 |
$77.50 |
| D9986 |
|
36 |
33 |
$0.00 |
| D1330 |
|
466 |
435 |
$0.00 |