| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
982 |
980 |
$80K |
| D2330 |
|
536 |
134 |
$40K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
58 |
30 |
$28K |
| D4341 |
|
371 |
99 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
325 |
325 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
356 |
354 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
244 |
113 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
178 |
93 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
211 |
211 |
$10K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
25 |
14 |
$3K |
| D2331 |
|
41 |
15 |
$3K |
| D2952 |
|
23 |
14 |
$2K |
| D5750 |
|
12 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
418 |
147 |
$2K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$259.20 |