| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
342 |
240 |
$162K |
| D1110 |
Prophylaxis - adult |
1,250 |
1,242 |
$108K |
| D0120 |
Periodic oral evaluation - established patient |
1,896 |
1,886 |
$105K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,058 |
1,053 |
$66K |
| D2160 |
|
691 |
371 |
$55K |
| D0274 |
Bitewings - four radiographic images |
2,170 |
2,155 |
$46K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,961 |
3,974 |
$41K |
| D1120 |
Prophylaxis - child |
1,037 |
1,035 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,297 |
2,284 |
$29K |
| D9430 |
|
747 |
742 |
$24K |
| D2954 |
|
219 |
169 |
$23K |
| D4341 |
|
212 |
64 |
$15K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
209 |
138 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,077 |
1,067 |
$13K |
| D1320 |
|
840 |
833 |
$11K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
74 |
37 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
91 |
56 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
96 |
96 |
$4K |
| D3221 |
|
49 |
38 |
$3K |
| D0272 |
Bitewings - two radiographic images |
219 |
218 |
$2K |
| D4910 |
|
15 |
15 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
13 |
$982.80 |
| D0374 |
|
16 |
16 |
$0.00 |