| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
820 |
688 |
$389K |
| D1110 |
Prophylaxis - adult |
3,915 |
3,901 |
$338K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,171 |
4,155 |
$273K |
| D0120 |
Periodic oral evaluation - established patient |
2,514 |
2,505 |
$195K |
| D0210 |
Intraoral - complete series of radiographic images |
3,606 |
3,594 |
$172K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,482 |
1,578 |
$166K |
| D4341 |
|
1,697 |
501 |
$119K |
| D2740 |
Crown - porcelain/ceramic |
241 |
207 |
$115K |
| D1206 |
Topical application of fluoride varnish |
5,862 |
5,838 |
$94K |
| D9430 |
|
2,562 |
2,420 |
$82K |
| D0230 |
Intraoral - periapical each additional radiographic image |
19,680 |
4,231 |
$81K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
169 |
159 |
$78K |
| D1120 |
Prophylaxis - child |
1,666 |
1,657 |
$75K |
| D4910 |
|
907 |
907 |
$68K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,040 |
647 |
$56K |
| D0274 |
Bitewings - four radiographic images |
2,418 |
2,411 |
$51K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
323 |
238 |
$26K |
| D0350 |
|
2,765 |
1,438 |
$25K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
80 |
50 |
$9K |
| D2954 |
|
72 |
55 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
424 |
413 |
$5K |
| D2330 |
|
59 |
39 |
$5K |
| D3221 |
|
67 |
63 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
20 |
17 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$288.00 |