| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
199 |
108 |
$105K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
73 |
52 |
$38K |
| D1110 |
Prophylaxis - adult |
1,050 |
1,037 |
$35K |
| D0274 |
Bitewings - four radiographic images |
959 |
945 |
$25K |
| D0330 |
Panoramic radiographic image |
631 |
622 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
270 |
106 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
695 |
684 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
691 |
682 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
202 |
128 |
$12K |
| D2954 |
|
107 |
58 |
$8K |
| D8670 |
Periodic orthodontic treatment visit |
66 |
66 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
771 |
702 |
$5K |
| D1330 |
|
455 |
446 |
$4K |
| D1310 |
|
454 |
445 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
266 |
237 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
38 |
25 |
$2K |
| D1206 |
Topical application of fluoride varnish |
136 |
136 |
$2K |
| D1120 |
Prophylaxis - child |
41 |
41 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
16 |
$1K |
| D9110 |
|
26 |
25 |
$802.38 |
| D1320 |
|
12 |
12 |
$238.92 |
| D1999 |
|
38 |
35 |
$0.00 |