| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
714 |
714 |
$47K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
83 |
57 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
330 |
328 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
387 |
114 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
380 |
380 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
256 |
101 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,196 |
778 |
$13K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
16 |
14 |
$7K |
| D0350 |
|
857 |
202 |
$7K |
| D0274 |
Bitewings - four radiographic images |
310 |
310 |
$6K |
| D1120 |
Prophylaxis - child |
131 |
126 |
$6K |
| D2954 |
|
58 |
43 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
342 |
337 |
$5K |
| D4341 |
|
58 |
16 |
$4K |
| D4910 |
|
39 |
39 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
33 |
18 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
28 |
$336.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$168.00 |
| D1999 |
|
19 |
19 |
$0.00 |