| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
635 |
464 |
$301K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,912 |
836 |
$226K |
| D0120 |
Periodic oral evaluation - established patient |
3,853 |
3,836 |
$212K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,562 |
2,554 |
$162K |
| D0230 |
Intraoral - periapical each additional radiographic image |
33,548 |
6,124 |
$136K |
| D1110 |
Prophylaxis - adult |
1,543 |
1,539 |
$130K |
| D1120 |
Prophylaxis - child |
3,304 |
3,287 |
$126K |
| D0274 |
Bitewings - four radiographic images |
4,625 |
4,609 |
$98K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,539 |
815 |
$83K |
| D2954 |
|
600 |
437 |
$63K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
733 |
423 |
$49K |
| D1351 |
Sealant - per tooth |
1,726 |
412 |
$48K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,280 |
3,267 |
$35K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
69 |
64 |
$32K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
404 |
227 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
1,278 |
1,252 |
$15K |
| D4341 |
|
226 |
87 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
221 |
82 |
$13K |
| D9430 |
|
318 |
314 |
$10K |
| D2160 |
|
64 |
42 |
$5K |
| D4910 |
|
64 |
64 |
$5K |
| D0272 |
Bitewings - two radiographic images |
336 |
336 |
$4K |
| D2335 |
|
29 |
12 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
47 |
47 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
26 |
14 |
$2K |
| D2330 |
|
20 |
15 |
$2K |