| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
635 |
406 |
$299K |
| D0120 |
Periodic oral evaluation - established patient |
4,179 |
4,162 |
$214K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,664 |
1,157 |
$185K |
| D1110 |
Prophylaxis - adult |
2,092 |
2,086 |
$169K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,592 |
2,580 |
$162K |
| D4910 |
|
1,488 |
1,485 |
$113K |
| D0230 |
Intraoral - periapical each additional radiographic image |
25,037 |
4,805 |
$100K |
| D0210 |
Intraoral - complete series of radiographic images |
2,109 |
2,102 |
$98K |
| D4341 |
|
1,428 |
395 |
$96K |
| D1120 |
Prophylaxis - child |
2,454 |
2,446 |
$85K |
| D0272 |
Bitewings - two radiographic images |
3,877 |
3,862 |
$44K |
| D2954 |
|
405 |
268 |
$42K |
| D9430 |
|
1,290 |
1,236 |
$41K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,139 |
3,124 |
$35K |
| D7140 |
Extraction, erupted tooth or exposed root |
359 |
169 |
$19K |
| D1351 |
Sealant - per tooth |
855 |
177 |
$18K |
| D3310 |
|
56 |
39 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
316 |
158 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,263 |
1,236 |
$14K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
17 |
16 |
$8K |
| D3320 |
|
14 |
12 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
71 |
41 |
$5K |
| D2330 |
|
29 |
12 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
14 |
$2K |
| D2140 |
|
19 |
15 |
$1K |
| D1206 |
Topical application of fluoride varnish |
50 |
50 |
$708.00 |