| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
465 |
286 |
$221K |
| D4910 |
|
2,598 |
2,587 |
$200K |
| D0120 |
Periodic oral evaluation - established patient |
3,328 |
3,308 |
$192K |
| D4341 |
|
2,756 |
772 |
$189K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,689 |
1,323 |
$180K |
| D1110 |
Prophylaxis - adult |
1,749 |
1,747 |
$146K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,138 |
554 |
$134K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,065 |
2,059 |
$128K |
| D9430 |
|
3,997 |
3,121 |
$127K |
| D1120 |
Prophylaxis - child |
2,506 |
2,484 |
$94K |
| D0210 |
Intraoral - complete series of radiographic images |
1,999 |
1,991 |
$92K |
| D0230 |
Intraoral - periapical each additional radiographic image |
19,474 |
5,441 |
$80K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
874 |
501 |
$69K |
| D0220 |
Intraoral - periapical first radiographic image |
5,490 |
4,623 |
$65K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,743 |
4,718 |
$57K |
| D0274 |
Bitewings - four radiographic images |
2,234 |
2,225 |
$47K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
812 |
412 |
$44K |
| D0350 |
|
2,531 |
1,314 |
$25K |
| D2954 |
|
225 |
142 |
$24K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
36 |
32 |
$17K |
| D4342 |
|
314 |
111 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
159 |
80 |
$9K |
| D1351 |
Sealant - per tooth |
271 |
59 |
$6K |
| D3320 |
|
15 |
13 |
$5K |
| D0272 |
Bitewings - two radiographic images |
277 |
270 |
$3K |
| D0240 |
|
251 |
128 |
$3K |
| D3221 |
|
33 |
19 |
$2K |
| D2330 |
|
16 |
12 |
$1K |
| D1320 |
|
37 |
37 |
$647.50 |
| D1330 |
|
263 |
263 |
$0.00 |