| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
258 |
172 |
$123K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,695 |
1,692 |
$109K |
| D0120 |
Periodic oral evaluation - established patient |
736 |
729 |
$43K |
| D0210 |
Intraoral - complete series of radiographic images |
925 |
924 |
$43K |
| D9430 |
|
1,308 |
1,192 |
$41K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,598 |
1,604 |
$31K |
| D1120 |
Prophylaxis - child |
759 |
756 |
$27K |
| D1206 |
Topical application of fluoride varnish |
1,283 |
1,273 |
$19K |
| D0274 |
Bitewings - four radiographic images |
807 |
803 |
$16K |
| D2954 |
|
131 |
89 |
$14K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
69 |
37 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
657 |
607 |
$8K |
| D1110 |
Prophylaxis - adult |
94 |
94 |
$8K |
| D4341 |
|
88 |
24 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
53 |
39 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
393 |
393 |
$3K |
| D0350 |
|
134 |
43 |
$1K |
| D1351 |
Sealant - per tooth |
56 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
49 |
49 |
$690.00 |
| D0272 |
Bitewings - two radiographic images |
55 |
50 |
$330.00 |