| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
179 |
116 |
$85K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
160 |
160 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
125 |
75 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
141 |
141 |
$7K |
| D4341 |
|
79 |
26 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
37 |
12 |
$4K |
| D9430 |
|
129 |
123 |
$4K |
| D0350 |
|
160 |
130 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$873.60 |
| D0330 |
Panoramic radiographic image |
35 |
35 |
$240.00 |