| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
499 |
314 |
$237K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,019 |
1,015 |
$67K |
| D4910 |
|
561 |
556 |
$42K |
| D1110 |
Prophylaxis - adult |
425 |
425 |
$35K |
| D0350 |
|
3,930 |
1,071 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
386 |
381 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,706 |
1,197 |
$24K |
| D1120 |
Prophylaxis - child |
411 |
411 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,063 |
1,057 |
$16K |
| D4341 |
|
189 |
52 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
274 |
274 |
$13K |
| D0330 |
Panoramic radiographic image |
446 |
444 |
$13K |
| D9430 |
|
328 |
313 |
$10K |
| D0274 |
Bitewings - four radiographic images |
403 |
402 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
665 |
654 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
57 |
24 |
$7K |
| D2160 |
|
23 |
12 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
20 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
67 |
67 |
$804.00 |