| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
270 |
143 |
$129K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
566 |
566 |
$37K |
| D0210 |
Intraoral - complete series of radiographic images |
554 |
554 |
$26K |
| D1110 |
Prophylaxis - adult |
270 |
270 |
$23K |
| D2954 |
|
157 |
109 |
$16K |
| D2140 |
|
290 |
88 |
$16K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
12 |
12 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
83 |
38 |
$5K |
| D0350 |
|
555 |
140 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
287 |
287 |
$4K |
| D4910 |
|
39 |
39 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
436 |
105 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
23 |
12 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
15 |
15 |
$1K |
| D1206 |
Topical application of fluoride varnish |
65 |
65 |
$1K |
| D9430 |
|
26 |
26 |
$832.00 |
| D0274 |
Bitewings - four radiographic images |
16 |
16 |
$324.00 |
| D0260 |
|
37 |
15 |
$181.25 |
| D0250 |
|
19 |
16 |
$175.70 |