| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
271 |
196 |
$129K |
| D0120 |
Periodic oral evaluation - established patient |
1,486 |
1,464 |
$101K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
808 |
320 |
$93K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
961 |
954 |
$64K |
| D1120 |
Prophylaxis - child |
1,198 |
1,182 |
$61K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
667 |
413 |
$43K |
| D1110 |
Prophylaxis - adult |
482 |
477 |
$43K |
| D0210 |
Intraoral - complete series of radiographic images |
808 |
802 |
$38K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,256 |
1,812 |
$34K |
| D0274 |
Bitewings - four radiographic images |
1,212 |
1,193 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,449 |
1,432 |
$22K |
| D2954 |
|
59 |
53 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
76 |
38 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
79 |
52 |
$4K |
| D4341 |
|
56 |
15 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
220 |
219 |
$3K |
| D1351 |
Sealant - per tooth |
69 |
12 |
$2K |
| D1310 |
|
25 |
25 |
$1K |
| D0272 |
Bitewings - two radiographic images |
45 |
45 |
$540.00 |