| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
433 |
302 |
$206K |
| D1110 |
Prophylaxis - adult |
1,897 |
1,878 |
$160K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,396 |
1,389 |
$84K |
| D0120 |
Periodic oral evaluation - established patient |
1,356 |
1,339 |
$59K |
| D4341 |
|
771 |
252 |
$51K |
| D0210 |
Intraoral - complete series of radiographic images |
1,094 |
1,091 |
$50K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,667 |
1,645 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
511 |
290 |
$34K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
599 |
314 |
$32K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
228 |
156 |
$26K |
| D2954 |
|
189 |
143 |
$20K |
| D0272 |
Bitewings - two radiographic images |
1,457 |
1,438 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,185 |
1,170 |
$16K |
| D2332 |
|
181 |
35 |
$14K |
| D1206 |
Topical application of fluoride varnish |
624 |
624 |
$11K |
| D3310 |
|
18 |
13 |
$5K |
| D1120 |
Prophylaxis - child |
135 |
135 |
$4K |
| D4910 |
|
56 |
56 |
$4K |
| D0350 |
|
493 |
246 |
$4K |
| D9430 |
|
79 |
78 |
$2K |
| D0330 |
Panoramic radiographic image |
60 |
58 |
$2K |