| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
112 |
71 |
$53K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
436 |
435 |
$29K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
155 |
27 |
$18K |
| D4341 |
|
247 |
66 |
$17K |
| D1110 |
Prophylaxis - adult |
158 |
158 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
267 |
266 |
$13K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
14 |
14 |
$6K |
| D1120 |
Prophylaxis - child |
90 |
90 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
61 |
27 |
$4K |
| D1206 |
Topical application of fluoride varnish |
226 |
226 |
$4K |
| D2954 |
|
18 |
14 |
$2K |
| D0274 |
Bitewings - four radiographic images |
82 |
82 |
$2K |
| D4910 |
|
14 |
14 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
221 |
113 |
$884.94 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$190.00 |
| D0350 |
|
30 |
30 |
$48.00 |