| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
142 |
88 |
$68K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
384 |
383 |
$25K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
348 |
108 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,751 |
646 |
$16K |
| D0274 |
Bitewings - four radiographic images |
477 |
476 |
$10K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
13 |
12 |
$6K |
| D0350 |
|
397 |
95 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
40 |
40 |
$3K |
| D2160 |
|
26 |
13 |
$2K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$682.50 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$576.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
39 |
39 |
$573.00 |