| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
619 |
392 |
$344K |
| D1110 |
Prophylaxis - adult |
5,027 |
4,881 |
$265K |
| D0120 |
Periodic oral evaluation - established patient |
5,203 |
5,067 |
$120K |
| D0274 |
Bitewings - four radiographic images |
2,581 |
2,508 |
$93K |
| D1120 |
Prophylaxis - child |
1,258 |
1,229 |
$63K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
732 |
496 |
$59K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,774 |
1,744 |
$51K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
67 |
65 |
$39K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
287 |
121 |
$38K |
| D2954 |
|
209 |
153 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
2,242 |
2,116 |
$34K |
| D0140 |
Limited oral evaluation - problem focused |
825 |
785 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
798 |
750 |
$31K |
| D0210 |
Intraoral - complete series of radiographic images |
268 |
251 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,618 |
872 |
$16K |
| D2950 |
|
74 |
51 |
$12K |
| D3320 |
|
21 |
14 |
$10K |
| D1351 |
Sealant - per tooth |
146 |
28 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
65 |
37 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$1K |
| D9110 |
|
28 |
25 |
$900.00 |
| D1999 |
|
124 |
104 |
$0.00 |