| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
117 |
75 |
$56K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
587 |
585 |
$38K |
| D0210 |
Intraoral - complete series of radiographic images |
484 |
482 |
$23K |
| D0350 |
|
2,460 |
668 |
$22K |
| D1110 |
Prophylaxis - adult |
181 |
181 |
$16K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
118 |
63 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
206 |
88 |
$13K |
| D4910 |
|
164 |
164 |
$12K |
| D9430 |
|
251 |
235 |
$8K |
| D1206 |
Topical application of fluoride varnish |
403 |
403 |
$7K |
| D1320 |
|
420 |
418 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
81 |
79 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
75 |
41 |
$6K |
| D4341 |
|
67 |
17 |
$5K |
| D1120 |
Prophylaxis - child |
45 |
45 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
499 |
245 |
$2K |
| D2954 |
|
13 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
35 |
35 |
$604.80 |
| D0220 |
Intraoral - periapical first radiographic image |
36 |
36 |
$432.00 |