| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
720 |
417 |
$341K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,919 |
1,919 |
$126K |
| D0210 |
Intraoral - complete series of radiographic images |
1,349 |
1,349 |
$64K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
856 |
438 |
$57K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
462 |
196 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
743 |
740 |
$49K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
649 |
300 |
$35K |
| D1120 |
Prophylaxis - child |
588 |
585 |
$24K |
| D4341 |
|
285 |
76 |
$20K |
| D1110 |
Prophylaxis - adult |
223 |
223 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,567 |
1,563 |
$20K |
| D2954 |
|
133 |
86 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
153 |
87 |
$12K |
| D4910 |
|
149 |
149 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,715 |
939 |
$7K |
| D0274 |
Bitewings - four radiographic images |
317 |
317 |
$7K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
14 |
13 |
$6K |
| D0272 |
Bitewings - two radiographic images |
531 |
531 |
$6K |
| D0330 |
Panoramic radiographic image |
157 |
157 |
$5K |
| D1351 |
Sealant - per tooth |
63 |
13 |
$2K |
| D0350 |
|
181 |
61 |
$2K |
| D2331 |
|
19 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
27 |
$324.00 |