| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
181 |
149 |
$72K |
| D1110 |
Prophylaxis - adult |
1,200 |
1,198 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
1,711 |
1,710 |
$43K |
| D1120 |
Prophylaxis - child |
771 |
771 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
647 |
428 |
$32K |
| D0140 |
Limited oral evaluation - problem focused |
502 |
478 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
885 |
883 |
$20K |
| D2954 |
|
118 |
95 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
2,166 |
1,966 |
$11K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
117 |
70 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
220 |
158 |
$9K |
| D0274 |
Bitewings - four radiographic images |
700 |
700 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
170 |
169 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,150 |
1,130 |
$4K |
| D0180 |
|
67 |
67 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
120 |
120 |
$3K |
| D0272 |
Bitewings - two radiographic images |
152 |
152 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
14 |
$960.00 |
| D2950 |
|
12 |
12 |
$660.00 |