| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
572 |
358 |
$272K |
| D0120 |
Periodic oral evaluation - established patient |
3,091 |
3,081 |
$170K |
| D1110 |
Prophylaxis - adult |
1,294 |
1,289 |
$113K |
| D0230 |
Intraoral - periapical each additional radiographic image |
18,276 |
3,056 |
$75K |
| D1120 |
Prophylaxis - child |
1,617 |
1,615 |
$58K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,098 |
4,087 |
$53K |
| D4910 |
|
680 |
680 |
$52K |
| D2954 |
|
465 |
297 |
$49K |
| D0210 |
Intraoral - complete series of radiographic images |
761 |
759 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
459 |
458 |
$29K |
| D4341 |
|
340 |
92 |
$24K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
43 |
39 |
$20K |
| D0272 |
Bitewings - two radiographic images |
1,428 |
1,423 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
573 |
563 |
$7K |
| D3320 |
|
18 |
14 |
$7K |
| D0350 |
|
521 |
250 |
$5K |
| D2140 |
|
76 |
39 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
24 |
14 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
12 |
$1K |
| D9430 |
|
14 |
12 |
$448.00 |
| D1320 |
|
29 |
29 |
$405.00 |