| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
187 |
135 |
$102K |
| D1110 |
Prophylaxis - adult |
1,682 |
1,680 |
$89K |
| D0120 |
Periodic oral evaluation - established patient |
1,246 |
1,244 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
353 |
202 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,696 |
1,684 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
866 |
865 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,583 |
1,569 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
505 |
505 |
$15K |
| D1120 |
Prophylaxis - child |
294 |
294 |
$13K |
| D1351 |
Sealant - per tooth |
270 |
83 |
$11K |
| D2954 |
|
77 |
57 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
708 |
708 |
$10K |
| D0272 |
Bitewings - two radiographic images |
326 |
326 |
$5K |
| D0274 |
Bitewings - four radiographic images |
151 |
150 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
25 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
135 |
134 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
14 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
15 |
12 |
$675.00 |