| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
257 |
183 |
$122K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,443 |
1,443 |
$94K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
78 |
70 |
$35K |
| D4341 |
|
446 |
124 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
462 |
236 |
$31K |
| D0210 |
Intraoral - complete series of radiographic images |
566 |
566 |
$27K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
191 |
101 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,425 |
1,004 |
$18K |
| D0274 |
Bitewings - four radiographic images |
849 |
849 |
$17K |
| D9430 |
|
527 |
509 |
$17K |
| D2954 |
|
159 |
110 |
$17K |
| D4910 |
|
181 |
181 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
215 |
137 |
$11K |
| D1120 |
Prophylaxis - child |
171 |
171 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
65 |
65 |
$5K |
| D1206 |
Topical application of fluoride varnish |
296 |
296 |
$4K |
| D0330 |
Panoramic radiographic image |
126 |
126 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
107 |
105 |
$1K |
| D0350 |
|
84 |
68 |
$816.00 |