| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
356 |
267 |
$169K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,514 |
1,507 |
$99K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,191 |
701 |
$79K |
| D1110 |
Prophylaxis - adult |
870 |
870 |
$75K |
| D0210 |
Intraoral - complete series of radiographic images |
1,215 |
1,212 |
$57K |
| D0120 |
Periodic oral evaluation - established patient |
718 |
716 |
$54K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
914 |
472 |
$49K |
| D4910 |
|
585 |
581 |
$44K |
| D9430 |
|
1,154 |
1,076 |
$37K |
| D1120 |
Prophylaxis - child |
789 |
786 |
$35K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
244 |
140 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,889 |
1,884 |
$26K |
| D4341 |
|
293 |
79 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,008 |
1,397 |
$20K |
| D0350 |
|
1,784 |
754 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
128 |
78 |
$10K |
| D0274 |
Bitewings - four radiographic images |
460 |
459 |
$9K |
| D1320 |
|
238 |
238 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
264 |
254 |
$3K |
| D1351 |
Sealant - per tooth |
83 |
26 |
$2K |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$156.00 |
| D1999 |
|
164 |
137 |
$138.00 |
| D1204 |
|
17 |
17 |
$0.00 |