| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
52 |
39 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
187 |
136 |
$15K |
| D9110 |
|
172 |
161 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
202 |
202 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
58 |
48 |
$6K |
| D4341 |
|
31 |
18 |
$6K |
| D1110 |
Prophylaxis - adult |
102 |
102 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
47 |
37 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
168 |
168 |
$4K |
| D1120 |
Prophylaxis - child |
89 |
89 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
72 |
61 |
$3K |
| D0330 |
Panoramic radiographic image |
116 |
114 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
252 |
205 |
$3K |
| D0274 |
Bitewings - four radiographic images |
125 |
125 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
141 |
141 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
258 |
255 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
41 |
41 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$248.56 |