| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
278 |
217 |
$132K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
791 |
791 |
$52K |
| D0210 |
Intraoral - complete series of radiographic images |
730 |
730 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
518 |
256 |
$34K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
239 |
134 |
$28K |
| D2954 |
|
207 |
166 |
$21K |
| D1110 |
Prophylaxis - adult |
221 |
221 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
253 |
152 |
$14K |
| D0350 |
|
1,464 |
463 |
$14K |
| D0330 |
Panoramic radiographic image |
461 |
458 |
$14K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
16 |
13 |
$7K |
| D9430 |
|
138 |
138 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
37 |
28 |
$3K |
| D1120 |
Prophylaxis - child |
45 |
45 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
493 |
132 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
49 |
49 |
$631.00 |
| D0274 |
Bitewings - four radiographic images |
32 |
32 |
$604.80 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$185.50 |