| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
229 |
174 |
$109K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
945 |
945 |
$62K |
| D9430 |
|
1,377 |
1,269 |
$44K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,545 |
1,853 |
$39K |
| D0274 |
Bitewings - four radiographic images |
1,089 |
1,088 |
$23K |
| D4341 |
|
261 |
69 |
$18K |
| D2954 |
|
122 |
104 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
158 |
158 |
$12K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
83 |
56 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
392 |
387 |
$5K |
| D1120 |
Prophylaxis - child |
46 |
46 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
16 |
$1K |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$1K |
| D0330 |
Panoramic radiographic image |
28 |
28 |
$840.00 |
| D0350 |
|
19 |
12 |
$182.40 |