| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
85 |
68 |
$90K |
| D2954 |
|
129 |
119 |
$36K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
281 |
253 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
253 |
219 |
$34K |
| D1110 |
Prophylaxis - adult |
537 |
537 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
804 |
804 |
$22K |
| D7140 |
Extraction, erupted tooth or exposed root |
146 |
124 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
140 |
126 |
$21K |
| D0274 |
Bitewings - four radiographic images |
592 |
592 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
356 |
356 |
$10K |
| D3320 |
|
13 |
12 |
$4K |
| D0330 |
Panoramic radiographic image |
151 |
151 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
303 |
301 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
218 |
216 |
$3K |
| D1120 |
Prophylaxis - child |
54 |
54 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
13 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$350.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
23 |
23 |
$308.00 |