| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
461 |
461 |
$30K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
59 |
31 |
$28K |
| D9430 |
|
663 |
480 |
$21K |
| D0350 |
|
2,243 |
566 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
437 |
437 |
$21K |
| D1110 |
Prophylaxis - adult |
146 |
146 |
$13K |
| D0330 |
Panoramic radiographic image |
436 |
436 |
$13K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
94 |
39 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
145 |
58 |
$10K |
| D4341 |
|
132 |
36 |
$9K |
| D4910 |
|
98 |
98 |
$8K |
| D1320 |
|
393 |
393 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,435 |
545 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
302 |
302 |
$5K |
| D2954 |
|
21 |
12 |
$2K |
| D1120 |
Prophylaxis - child |
37 |
37 |
$2K |
| D0272 |
Bitewings - two radiographic images |
62 |
62 |
$712.00 |