| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
681 |
488 |
$477K |
| D1110 |
Prophylaxis - adult |
3,044 |
3,044 |
$167K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,283 |
1,901 |
$164K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,399 |
1,290 |
$134K |
| D0120 |
Periodic oral evaluation - established patient |
3,194 |
3,193 |
$88K |
| D9945 |
|
516 |
516 |
$74K |
| D0330 |
Panoramic radiographic image |
2,049 |
2,048 |
$71K |
| D1120 |
Prophylaxis - child |
1,508 |
1,507 |
$64K |
| D7140 |
Extraction, erupted tooth or exposed root |
633 |
561 |
$60K |
| D0274 |
Bitewings - four radiographic images |
1,902 |
1,902 |
$54K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,582 |
1,581 |
$47K |
| D0220 |
Intraoral - periapical first radiographic image |
2,679 |
2,593 |
$35K |
| D2954 |
|
190 |
165 |
$33K |
| D0210 |
Intraoral - complete series of radiographic images |
1,315 |
1,304 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,681 |
1,680 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
1,710 |
1,697 |
$23K |
| D2330 |
|
286 |
244 |
$22K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
92 |
90 |
$11K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
12 |
12 |
$6K |
| D0272 |
Bitewings - two radiographic images |
314 |
314 |
$5K |
| D1206 |
Topical application of fluoride varnish |
144 |
144 |
$4K |
| D2332 |
|
37 |
36 |
$4K |
| D4910 |
|
42 |
42 |
$2K |
| D1351 |
Sealant - per tooth |
41 |
25 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
12 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
110 |
110 |
$755.36 |