| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
448 |
368 |
$213K |
| D9430 |
|
4,680 |
3,925 |
$148K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,336 |
1,334 |
$86K |
| D0210 |
Intraoral - complete series of radiographic images |
1,647 |
1,645 |
$78K |
| D2954 |
|
488 |
407 |
$51K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
303 |
157 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
298 |
175 |
$19K |
| D4341 |
|
262 |
72 |
$18K |
| D0350 |
|
1,379 |
762 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,310 |
1,200 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,444 |
1,549 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
187 |
108 |
$10K |
| D1110 |
Prophylaxis - adult |
87 |
87 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
144 |
144 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
376 |
376 |
$5K |
| D0274 |
Bitewings - four radiographic images |
134 |
134 |
$3K |
| D1120 |
Prophylaxis - child |
79 |
79 |
$2K |
| D0270 |
|
131 |
127 |
$644.05 |