| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
109 |
55 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
1,136 |
1,134 |
$46K |
| D1110 |
Prophylaxis - adult |
581 |
580 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
745 |
742 |
$45K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
638 |
395 |
$43K |
| D7140 |
Extraction, erupted tooth or exposed root |
645 |
384 |
$37K |
| D0210 |
Intraoral - complete series of radiographic images |
787 |
786 |
$37K |
| D1120 |
Prophylaxis - child |
1,153 |
1,151 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
574 |
264 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,596 |
1,433 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
309 |
148 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,780 |
1,777 |
$19K |
| D9430 |
|
562 |
530 |
$17K |
| D2140 |
|
301 |
178 |
$16K |
| D0350 |
|
1,728 |
780 |
$16K |
| D1351 |
Sealant - per tooth |
713 |
230 |
$15K |
| D0272 |
Bitewings - two radiographic images |
1,142 |
1,140 |
$13K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
107 |
46 |
$12K |
| D2954 |
|
103 |
55 |
$11K |
| D4341 |
|
120 |
33 |
$8K |
| D4910 |
|
106 |
106 |
$8K |
| D2330 |
|
58 |
29 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
54 |
43 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
233 |
211 |
$3K |
| D9110 |
|
27 |
25 |
$1K |
| D1320 |
|
82 |
82 |
$1K |
| D2160 |
|
16 |
13 |
$1K |
| D3221 |
|
13 |
12 |
$819.00 |