| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
727 |
727 |
$48K |
| D1110 |
Prophylaxis - adult |
508 |
508 |
$45K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
94 |
57 |
$38K |
| D0210 |
Intraoral - complete series of radiographic images |
648 |
648 |
$31K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
228 |
128 |
$27K |
| D4910 |
|
126 |
126 |
$10K |
| D9430 |
|
299 |
294 |
$10K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
143 |
77 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
560 |
560 |
$8K |
| D4341 |
|
96 |
25 |
$7K |
| D0350 |
|
362 |
144 |
$3K |
| D0330 |
Panoramic radiographic image |
88 |
88 |
$3K |
| D1120 |
Prophylaxis - child |
49 |
49 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
15 |
$2K |
| D2140 |
|
23 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
244 |
54 |
$984.15 |