| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
141 |
95 |
$67K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,060 |
1,054 |
$66K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
459 |
211 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
788 |
788 |
$40K |
| D0210 |
Intraoral - complete series of radiographic images |
554 |
551 |
$26K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
366 |
154 |
$23K |
| D1120 |
Prophylaxis - child |
514 |
510 |
$20K |
| D0274 |
Bitewings - four radiographic images |
854 |
854 |
$17K |
| D4910 |
|
209 |
209 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,072 |
1,068 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,342 |
1,213 |
$13K |
| D4341 |
|
148 |
39 |
$10K |
| D1110 |
Prophylaxis - adult |
43 |
43 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
174 |
172 |
$2K |
| D1330 |
|
1,649 |
1,643 |
$0.00 |