| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
202 |
151 |
$96K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,062 |
1,062 |
$70K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
421 |
162 |
$50K |
| D1120 |
Prophylaxis - child |
572 |
572 |
$29K |
| D1110 |
Prophylaxis - adult |
328 |
326 |
$29K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
342 |
189 |
$23K |
| D4341 |
|
275 |
73 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,280 |
863 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
342 |
342 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
923 |
919 |
$14K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
29 |
27 |
$13K |
| D2954 |
|
107 |
83 |
$11K |
| D1351 |
Sealant - per tooth |
244 |
59 |
$9K |
| D0272 |
Bitewings - two radiographic images |
640 |
639 |
$8K |
| D2160 |
|
84 |
59 |
$7K |
| D4910 |
|
86 |
86 |
$6K |
| D2140 |
|
97 |
61 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
84 |
54 |
$5K |
| D9430 |
|
135 |
133 |
$4K |
| D0350 |
|
332 |
141 |
$3K |
| D2335 |
|
23 |
14 |
$3K |
| D2330 |
|
24 |
17 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
16 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
118 |
114 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
30 |
30 |
$1K |
| D0270 |
|
27 |
26 |
$135.00 |