| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
643 |
493 |
$231K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,841 |
709 |
$133K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,484 |
912 |
$100K |
| D1110 |
Prophylaxis - adult |
2,346 |
2,253 |
$73K |
| D0120 |
Periodic oral evaluation - established patient |
2,369 |
2,255 |
$49K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,508 |
1,455 |
$49K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
530 |
345 |
$43K |
| D0210 |
Intraoral - complete series of radiographic images |
865 |
865 |
$33K |
| D0140 |
Limited oral evaluation - problem focused |
2,180 |
2,031 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
393 |
230 |
$23K |
| D2335 |
|
260 |
113 |
$22K |
| D2954 |
|
374 |
307 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
4,681 |
4,369 |
$21K |
| D0274 |
Bitewings - four radiographic images |
2,358 |
2,230 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,708 |
3,359 |
$16K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
33 |
33 |
$11K |
| D1120 |
Prophylaxis - child |
529 |
525 |
$10K |
| D0330 |
Panoramic radiographic image |
1,014 |
951 |
$9K |
| D2332 |
|
101 |
27 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
439 |
438 |
$3K |
| D4355 |
|
26 |
26 |
$2K |
| D4341 |
|
23 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
17 |
17 |
$143.00 |
| D1999 |
|
49 |
47 |
$0.00 |