| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9430 |
|
1,229 |
1,217 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
642 |
642 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
789 |
781 |
$33K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
37 |
16 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,343 |
1,085 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
374 |
374 |
$16K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
235 |
116 |
$14K |
| D1110 |
Prophylaxis - adult |
151 |
149 |
$11K |
| D1120 |
Prophylaxis - child |
362 |
353 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
753 |
748 |
$9K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
85 |
66 |
$9K |
| D0272 |
Bitewings - two radiographic images |
612 |
600 |
$6K |
| D4341 |
|
48 |
12 |
$3K |
| D2140 |
|
52 |
26 |
$3K |
| D1320 |
|
119 |
116 |
$2K |
| D2160 |
|
16 |
12 |
$1K |
| D3221 |
|
16 |
13 |
$976.00 |