| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
166 |
123 |
$79K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
85 |
83 |
$39K |
| D2954 |
|
155 |
118 |
$16K |
| D9430 |
|
483 |
474 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
128 |
128 |
$8K |
| D3320 |
|
13 |
12 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
104 |
104 |
$5K |
| D0350 |
|
417 |
149 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
34 |
25 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
687 |
425 |
$3K |
| D0272 |
Bitewings - two radiographic images |
147 |
147 |
$2K |
| D0270 |
|
219 |
219 |
$1K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
38 |
38 |
$659.00 |