| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
118 |
76 |
$55K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
816 |
810 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
961 |
958 |
$51K |
| D0210 |
Intraoral - complete series of radiographic images |
994 |
990 |
$44K |
| D1120 |
Prophylaxis - child |
630 |
629 |
$24K |
| D1110 |
Prophylaxis - adult |
178 |
178 |
$16K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
138 |
79 |
$9K |
| D0350 |
|
988 |
459 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
511 |
511 |
$5K |
| D0274 |
Bitewings - four radiographic images |
280 |
278 |
$5K |
| D2160 |
|
60 |
41 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
80 |
26 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
64 |
37 |
$4K |
| D2954 |
|
25 |
16 |
$3K |
| D1206 |
Topical application of fluoride varnish |
105 |
105 |
$2K |
| D2330 |
|
21 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
12 |
$1K |
| D2140 |
|
18 |
12 |
$982.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
108 |
30 |
$318.00 |