| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,191 |
1,191 |
$44K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
63 |
57 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
1,068 |
1,068 |
$22K |
| D2954 |
|
164 |
143 |
$20K |
| D0274 |
Bitewings - four radiographic images |
967 |
967 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
179 |
172 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,238 |
1,236 |
$12K |
| D2332 |
|
74 |
71 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,229 |
1,228 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
177 |
177 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
159 |
159 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
28 |
28 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
12 |
12 |
$727.40 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
12 |
12 |
$578.98 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$155.00 |