| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
252 |
169 |
$120K |
| D0120 |
Periodic oral evaluation - established patient |
1,714 |
1,704 |
$98K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,098 |
1,089 |
$71K |
| D1120 |
Prophylaxis - child |
1,260 |
1,247 |
$47K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,767 |
2,171 |
$41K |
| D0210 |
Intraoral - complete series of radiographic images |
848 |
843 |
$40K |
| D4910 |
|
412 |
412 |
$32K |
| D0274 |
Bitewings - four radiographic images |
1,343 |
1,334 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,752 |
1,738 |
$21K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
156 |
77 |
$19K |
| D2952 |
|
174 |
126 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
103 |
56 |
$7K |
| D4342 |
|
68 |
19 |
$3K |
| D4341 |
|
39 |
12 |
$3K |
| D2940 |
|
47 |
16 |
$3K |
| D1110 |
Prophylaxis - adult |
28 |
28 |
$3K |
| D9430 |
|
80 |
80 |
$2K |
| D2394 |
|
24 |
14 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
22 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
89 |
89 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$1K |
| D0350 |
|
54 |
36 |
$556.80 |