| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
1,090 |
845 |
$572K |
| D1110 |
Prophylaxis - adult |
3,276 |
3,276 |
$81K |
| D0210 |
Intraoral - complete series of radiographic images |
1,900 |
1,900 |
$72K |
| D0120 |
Periodic oral evaluation - established patient |
2,860 |
2,860 |
$62K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
179 |
178 |
$57K |
| D2954 |
|
762 |
572 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,155 |
1,155 |
$39K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
399 |
176 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
457 |
278 |
$25K |
| D9310 |
|
927 |
924 |
$23K |
| D9222 |
|
178 |
177 |
$22K |
| D7240 |
Removal of impacted tooth - completely bony |
72 |
24 |
$20K |
| D3320 |
|
57 |
49 |
$17K |
| D0274 |
Bitewings - four radiographic images |
1,005 |
1,005 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
2,023 |
2,003 |
$11K |
| D1120 |
Prophylaxis - child |
510 |
510 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,482 |
1,477 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
401 |
397 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
103 |
57 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
187 |
187 |
$1K |
| D2950 |
|
13 |
12 |
$848.25 |
| D0330 |
Panoramic radiographic image |
28 |
28 |
$639.52 |
| D1206 |
Topical application of fluoride varnish |
40 |
40 |
$600.00 |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$116.00 |
| D0270 |
|
26 |
26 |
$113.10 |