| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
726 |
367 |
$345K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
5,666 |
1,294 |
$306K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,261 |
2,257 |
$142K |
| D1110 |
Prophylaxis - adult |
1,735 |
1,732 |
$135K |
| D2330 |
|
1,202 |
407 |
$94K |
| D2954 |
|
689 |
364 |
$72K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,070 |
619 |
$71K |
| D0210 |
Intraoral - complete series of radiographic images |
1,018 |
1,018 |
$48K |
| D4341 |
|
651 |
178 |
$46K |
| D3320 |
|
118 |
77 |
$43K |
| D0350 |
|
1,700 |
1,361 |
$38K |
| D0330 |
Panoramic radiographic image |
1,321 |
1,318 |
$37K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
306 |
132 |
$36K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
69 |
53 |
$32K |
| D9430 |
|
944 |
872 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,013 |
2,006 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
350 |
350 |
$23K |
| D2331 |
|
195 |
115 |
$15K |
| D2335 |
|
113 |
26 |
$13K |
| D1120 |
Prophylaxis - child |
288 |
287 |
$11K |
| D1320 |
|
417 |
417 |
$7K |
| D0272 |
Bitewings - two radiographic images |
90 |
90 |
$900.00 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$210.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$108.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
17 |
15 |
$85.05 |
| D0274 |
Bitewings - four radiographic images |
42 |
41 |
$18.00 |