| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
452 |
304 |
$215K |
| D0120 |
Periodic oral evaluation - established patient |
3,209 |
3,203 |
$172K |
| D1110 |
Prophylaxis - adult |
1,655 |
1,655 |
$139K |
| D0230 |
Intraoral - periapical each additional radiographic image |
30,139 |
5,249 |
$119K |
| D9430 |
|
3,177 |
2,946 |
$101K |
| D1120 |
Prophylaxis - child |
2,439 |
2,433 |
$89K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,322 |
1,322 |
$82K |
| D0274 |
Bitewings - four radiographic images |
3,800 |
3,793 |
$81K |
| D0220 |
Intraoral - periapical first radiographic image |
6,145 |
5,019 |
$72K |
| D2920 |
|
594 |
225 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,286 |
2,279 |
$23K |
| D2161 |
|
130 |
113 |
$11K |
| D9110 |
|
158 |
156 |
$10K |
| D1351 |
Sealant - per tooth |
417 |
74 |
$9K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
117 |
77 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
135 |
66 |
$8K |
| D4341 |
|
56 |
15 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
22 |
15 |
$2K |
| D3221 |
|
15 |
12 |
$945.00 |