| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
384 |
230 |
$183K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
555 |
553 |
$33K |
| D2954 |
|
288 |
175 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
481 |
481 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
946 |
929 |
$18K |
| D5750 |
|
61 |
61 |
$12K |
| D5751 |
|
55 |
55 |
$11K |
| D1110 |
Prophylaxis - adult |
109 |
109 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
406 |
399 |
$5K |
| D0272 |
Bitewings - two radiographic images |
187 |
185 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
17 |
12 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
15 |
$1K |
| D5851 |
|
17 |
17 |
$1K |
| D5850 |
|
15 |
15 |
$910.00 |