| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
136 |
88 |
$64K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
892 |
885 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
840 |
838 |
$51K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,432 |
1,850 |
$30K |
| D0274 |
Bitewings - four radiographic images |
1,060 |
1,050 |
$22K |
| D1110 |
Prophylaxis - adult |
232 |
232 |
$20K |
| D1120 |
Prophylaxis - child |
208 |
207 |
$9K |
| D2954 |
|
67 |
43 |
$7K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
13 |
12 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
15 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
41 |
41 |
$618.00 |
| D9430 |
|
17 |
17 |
$544.00 |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$260.00 |
| D0220 |
Intraoral - periapical first radiographic image |
24 |
24 |
$239.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$114.00 |
| D1999 |
|
39 |
35 |
$0.00 |