| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
36 |
29 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
189 |
36 |
$11K |
| D1110 |
Prophylaxis - adult |
189 |
183 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
229 |
224 |
$5K |
| D1206 |
Topical application of fluoride varnish |
225 |
219 |
$5K |
| D1120 |
Prophylaxis - child |
130 |
128 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
60 |
37 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
75 |
66 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
135 |
124 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
45 |
28 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
24 |
16 |
$3K |
| D0330 |
Panoramic radiographic image |
67 |
65 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
60 |
59 |
$2K |
| D0274 |
Bitewings - four radiographic images |
79 |
78 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
193 |
182 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
13 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
49 |
47 |
$1K |
| D0272 |
Bitewings - two radiographic images |
42 |
41 |
$700.14 |
| D2950 |
|
14 |
13 |
$665.35 |
| D0230 |
Intraoral - periapical each additional radiographic image |
120 |
101 |
$600.87 |