| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
298 |
212 |
$142K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,347 |
1,340 |
$89K |
| D1110 |
Prophylaxis - adult |
689 |
686 |
$60K |
| D0210 |
Intraoral - complete series of radiographic images |
1,116 |
1,108 |
$53K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
341 |
186 |
$38K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
452 |
218 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
321 |
197 |
$21K |
| D4341 |
|
120 |
45 |
$8K |
| D2954 |
|
67 |
57 |
$7K |
| D0350 |
|
772 |
352 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
98 |
98 |
$7K |
| D0274 |
Bitewings - four radiographic images |
88 |
88 |
$2K |
| D1120 |
Prophylaxis - child |
18 |
17 |
$840.00 |
| D0220 |
Intraoral - periapical first radiographic image |
30 |
30 |
$360.00 |