| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
376 |
237 |
$179K |
| D0120 |
Periodic oral evaluation - established patient |
1,129 |
1,111 |
$89K |
| D1110 |
Prophylaxis - adult |
941 |
931 |
$82K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,978 |
1,656 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
535 |
533 |
$35K |
| D0274 |
Bitewings - four radiographic images |
1,546 |
1,529 |
$32K |
| D1120 |
Prophylaxis - child |
552 |
543 |
$28K |
| D4341 |
|
311 |
84 |
$21K |
| D2952 |
|
94 |
63 |
$10K |
| D1206 |
Topical application of fluoride varnish |
547 |
539 |
$8K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
16 |
13 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
31 |
14 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
20 |
12 |
$1K |