| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
146 |
89 |
$69K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
687 |
685 |
$45K |
| D0210 |
Intraoral - complete series of radiographic images |
578 |
577 |
$27K |
| D1110 |
Prophylaxis - adult |
215 |
215 |
$19K |
| D2954 |
|
148 |
90 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
96 |
96 |
$7K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
12 |
12 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
325 |
323 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
17 |
14 |
$2K |
| D9430 |
|
50 |
50 |
$2K |
| D4910 |
|
14 |
14 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
63 |
12 |
$275.40 |