| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
348 |
233 |
$165K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,571 |
1,566 |
$103K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,002 |
415 |
$67K |
| D0210 |
Intraoral - complete series of radiographic images |
1,298 |
1,294 |
$62K |
| D4910 |
|
635 |
634 |
$49K |
| D1110 |
Prophylaxis - adult |
474 |
474 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
479 |
473 |
$38K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
145 |
68 |
$17K |
| D2954 |
|
134 |
97 |
$14K |
| D9430 |
|
410 |
397 |
$13K |
| D1206 |
Topical application of fluoride varnish |
732 |
731 |
$12K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
25 |
25 |
$12K |
| D4341 |
|
153 |
40 |
$11K |
| D0274 |
Bitewings - four radiographic images |
534 |
528 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
131 |
61 |
$9K |
| D1120 |
Prophylaxis - child |
178 |
178 |
$8K |
| D2160 |
|
89 |
63 |
$7K |
| D2140 |
|
122 |
58 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,400 |
682 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
300 |
291 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
23 |
13 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
38 |
38 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$103.00 |