| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
519 |
359 |
$246K |
| D9430 |
|
5,155 |
3,979 |
$165K |
| D1110 |
Prophylaxis - adult |
1,900 |
1,894 |
$163K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,298 |
2,291 |
$147K |
| D0120 |
Periodic oral evaluation - established patient |
1,823 |
1,818 |
$108K |
| D0210 |
Intraoral - complete series of radiographic images |
1,987 |
1,978 |
$94K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
584 |
238 |
$67K |
| D2954 |
|
460 |
331 |
$48K |
| D0220 |
Intraoral - periapical first radiographic image |
3,543 |
2,785 |
$42K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
90 |
83 |
$41K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,989 |
2,980 |
$41K |
| D0330 |
Panoramic radiographic image |
1,089 |
1,082 |
$32K |
| D1120 |
Prophylaxis - child |
739 |
739 |
$31K |
| D0274 |
Bitewings - four radiographic images |
1,298 |
1,295 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,141 |
2,202 |
$21K |
| D4341 |
|
195 |
55 |
$14K |
| D1351 |
Sealant - per tooth |
156 |
33 |
$6K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$144.00 |