| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
1,014 |
765 |
$445K |
| D0120 |
Periodic oral evaluation - established patient |
5,062 |
5,057 |
$185K |
| D1120 |
Prophylaxis - child |
4,751 |
4,745 |
$173K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,746 |
1,577 |
$159K |
| D1351 |
Sealant - per tooth |
4,144 |
1,060 |
$126K |
| D1110 |
Prophylaxis - adult |
1,633 |
1,631 |
$123K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,543 |
6,536 |
$117K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,437 |
915 |
$102K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,686 |
1,683 |
$97K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,914 |
6,686 |
$91K |
| D9999 |
Unspecified adjunctive procedure, by report |
630 |
585 |
$81K |
| D4341 |
|
1,180 |
461 |
$61K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,241 |
763 |
$60K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
122 |
110 |
$57K |
| D0220 |
Intraoral - periapical first radiographic image |
6,800 |
6,166 |
$46K |
| D0274 |
Bitewings - four radiographic images |
3,955 |
3,952 |
$46K |
| D9430 |
|
1,777 |
1,693 |
$42K |
| D2954 |
|
503 |
414 |
$40K |
| D0210 |
Intraoral - complete series of radiographic images |
1,047 |
1,047 |
$34K |
| D2332 |
|
299 |
202 |
$21K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
204 |
153 |
$20K |
| D4910 |
|
309 |
309 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
319 |
203 |
$17K |
| D3320 |
|
15 |
15 |
$5K |
| D2331 |
|
33 |
26 |
$2K |
| D4342 |
|
27 |
12 |
$954.00 |
| D1999 |
|
18 |
15 |
$20.00 |
| D1330 |
|
1,466 |
1,464 |
$0.00 |
| D2950 |
|
21 |
16 |
$0.00 |