| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
48 |
38 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
224 |
224 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
242 |
242 |
$16K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
195 |
128 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,010 |
575 |
$12K |
| D1110 |
Prophylaxis - adult |
113 |
113 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
177 |
177 |
$8K |
| D2140 |
|
92 |
45 |
$5K |
| D0274 |
Bitewings - four radiographic images |
151 |
151 |
$3K |
| D1206 |
Topical application of fluoride varnish |
127 |
127 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
19 |
15 |
$2K |
| D1120 |
Prophylaxis - child |
43 |
43 |
$2K |
| D9430 |
|
37 |
36 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
43 |
43 |
$619.50 |
| D0220 |
Intraoral - periapical first radiographic image |
29 |
26 |
$348.00 |