| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
109 |
60 |
$52K |
| D2740 |
Crown - porcelain/ceramic |
76 |
47 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
533 |
533 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
388 |
173 |
$26K |
| D4341 |
|
348 |
92 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
465 |
465 |
$22K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
167 |
57 |
$20K |
| D1110 |
Prophylaxis - adult |
128 |
128 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
130 |
82 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
191 |
88 |
$10K |
| D9430 |
|
280 |
254 |
$9K |
| D0350 |
|
762 |
231 |
$7K |
| D1320 |
|
424 |
424 |
$7K |
| D3320 |
|
17 |
12 |
$6K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
12 |
12 |
$6K |
| D1206 |
Topical application of fluoride varnish |
271 |
271 |
$4K |
| D4342 |
|
89 |
28 |
$4K |
| D1120 |
Prophylaxis - child |
44 |
44 |
$2K |
| D4910 |
|
27 |
27 |
$2K |
| D2954 |
|
17 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
128 |
126 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
60 |
41 |
$243.00 |
| D1310 |
|
186 |
186 |
$46.00 |
| D1330 |
|
130 |
130 |
$0.00 |