| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
38 |
31 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
541 |
509 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
272 |
261 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
235 |
61 |
$14K |
| D1110 |
Prophylaxis - adult |
95 |
91 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
13 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
25 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
62 |
58 |
$2K |
| D2950 |
|
17 |
14 |
$2K |
| D1120 |
Prophylaxis - child |
44 |
44 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
54 |
54 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
65 |
61 |
$974.93 |
| D1206 |
Topical application of fluoride varnish |
32 |
32 |
$611.40 |
| D0274 |
Bitewings - four radiographic images |
16 |
16 |
$506.70 |