| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
1,549 |
1,030 |
$736K |
| D1110 |
Prophylaxis - adult |
3,728 |
3,713 |
$312K |
| D2954 |
|
1,667 |
1,148 |
$175K |
| D0230 |
Intraoral - periapical each additional radiographic image |
31,982 |
5,306 |
$134K |
| D4910 |
|
1,157 |
1,144 |
$89K |
| D0220 |
Intraoral - periapical first radiographic image |
7,359 |
7,041 |
$87K |
| D4341 |
|
1,171 |
361 |
$79K |
| D9110 |
|
1,228 |
1,077 |
$77K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,124 |
1,118 |
$70K |
| D9430 |
|
586 |
566 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
112 |
66 |
$6K |
| D2920 |
|
154 |
118 |
$6K |
| D3310 |
|
17 |
12 |
$5K |
| D1120 |
Prophylaxis - child |
126 |
126 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
12 |
12 |
$1K |
| D4342 |
|
34 |
15 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
110 |
110 |
$872.00 |
| D0120 |
Periodic oral evaluation - established patient |
41 |
41 |
$735.00 |