| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
137 |
74 |
$92K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
753 |
309 |
$61K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
312 |
151 |
$32K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
46 |
38 |
$23K |
| D2954 |
|
129 |
79 |
$23K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
268 |
135 |
$22K |
| D1110 |
Prophylaxis - adult |
432 |
432 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
218 |
98 |
$11K |
| D0274 |
Bitewings - four radiographic images |
416 |
416 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
359 |
358 |
$9K |
| D2394 |
|
54 |
37 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
237 |
237 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
397 |
393 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
104 |
104 |
$5K |
| D2335 |
|
19 |
12 |
$3K |
| D0330 |
Panoramic radiographic image |
135 |
135 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
180 |
172 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
29 |
$496.89 |