| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
863 |
863 |
$76K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
139 |
123 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
1,076 |
1,072 |
$61K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
622 |
616 |
$40K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,438 |
1,680 |
$35K |
| D0210 |
Intraoral - complete series of radiographic images |
592 |
585 |
$28K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
400 |
284 |
$27K |
| D0274 |
Bitewings - four radiographic images |
865 |
862 |
$18K |
| D1206 |
Topical application of fluoride varnish |
861 |
861 |
$15K |
| D4341 |
|
165 |
46 |
$12K |
| D2140 |
|
188 |
120 |
$10K |
| D9430 |
|
153 |
151 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
38 |
25 |
$5K |
| D2331 |
|
49 |
24 |
$4K |
| D4910 |
|
43 |
43 |
$3K |
| D1120 |
Prophylaxis - child |
76 |
76 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
146 |
146 |
$2K |
| D2160 |
|
12 |
12 |
$957.60 |
| D1208 |
Topical application of fluoride, excluding varnish |
64 |
64 |
$522.00 |