| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
673 |
451 |
$320K |
| D1110 |
Prophylaxis - adult |
2,308 |
2,279 |
$195K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,889 |
1,867 |
$118K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,633 |
751 |
$109K |
| D0120 |
Periodic oral evaluation - established patient |
1,629 |
1,617 |
$97K |
| D0210 |
Intraoral - complete series of radiographic images |
1,541 |
1,521 |
$71K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,060 |
436 |
$58K |
| D4910 |
|
530 |
529 |
$41K |
| D4341 |
|
576 |
158 |
$40K |
| D1206 |
Topical application of fluoride varnish |
2,056 |
2,040 |
$35K |
| D2952 |
|
301 |
220 |
$32K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
463 |
210 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,973 |
1,952 |
$28K |
| D1120 |
Prophylaxis - child |
616 |
612 |
$24K |
| D0274 |
Bitewings - four radiographic images |
1,064 |
1,053 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
219 |
124 |
$17K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
89 |
53 |
$11K |
| D2160 |
|
105 |
53 |
$8K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
16 |
14 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
768 |
722 |
$7K |
| D2140 |
|
125 |
53 |
$7K |
| D0272 |
Bitewings - two radiographic images |
444 |
444 |
$5K |
| D0350 |
|
407 |
146 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
284 |
283 |
$3K |
| D4342 |
|
43 |
12 |
$2K |
| D9430 |
|
25 |
24 |
$800.00 |
| D1330 |
|
45 |
45 |
$0.00 |