| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
175 |
121 |
$83K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
863 |
862 |
$57K |
| D4341 |
|
454 |
120 |
$32K |
| D4910 |
|
405 |
405 |
$31K |
| D3320 |
|
60 |
48 |
$22K |
| D1120 |
Prophylaxis - child |
404 |
404 |
$19K |
| D1110 |
Prophylaxis - adult |
215 |
215 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
281 |
162 |
$19K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
38 |
35 |
$18K |
| D2954 |
|
155 |
107 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
287 |
287 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
222 |
86 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,102 |
589 |
$13K |
| D1351 |
Sealant - per tooth |
328 |
81 |
$12K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
149 |
94 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
121 |
94 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
619 |
619 |
$10K |
| D0274 |
Bitewings - four radiographic images |
394 |
394 |
$9K |
| D3310 |
|
20 |
15 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
105 |
76 |
$6K |
| D4342 |
|
101 |
34 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
35 |
26 |
$4K |
| D9430 |
|
117 |
115 |
$4K |
| D2330 |
|
44 |
26 |
$4K |
| D2160 |
|
44 |
33 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
281 |
275 |
$3K |
| D0350 |
|
334 |
185 |
$3K |
| D0330 |
Panoramic radiographic image |
41 |
41 |
$1K |
| D2140 |
|
22 |
14 |
$1K |
| D0272 |
Bitewings - two radiographic images |
17 |
17 |
$204.00 |
| D1310 |
|
61 |
61 |
$46.00 |
| D0603 |
|
24 |
24 |
$15.00 |
| D0602 |
|
12 |
12 |
$0.00 |