| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
918 |
448 |
$435K |
| D2740 |
Crown - porcelain/ceramic |
819 |
400 |
$389K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
548 |
393 |
$252K |
| D2954 |
|
1,614 |
761 |
$169K |
| D3320 |
|
378 |
265 |
$138K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,507 |
1,506 |
$99K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,788 |
684 |
$97K |
| D1110 |
Prophylaxis - adult |
1,021 |
1,019 |
$89K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,035 |
477 |
$82K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
661 |
419 |
$78K |
| D0210 |
Intraoral - complete series of radiographic images |
1,324 |
1,322 |
$63K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
817 |
471 |
$55K |
| D4341 |
|
548 |
143 |
$38K |
| D2331 |
|
366 |
172 |
$29K |
| D9430 |
|
876 |
771 |
$28K |
| D3310 |
|
88 |
47 |
$26K |
| D0350 |
|
2,180 |
809 |
$22K |
| D1320 |
|
1,154 |
1,152 |
$19K |
| D0330 |
Panoramic radiographic image |
651 |
648 |
$19K |
| D2330 |
|
225 |
123 |
$18K |
| D4342 |
|
285 |
81 |
$12K |
| D1206 |
Topical application of fluoride varnish |
546 |
544 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
615 |
615 |
$9K |
| D4910 |
|
83 |
83 |
$6K |
| D2332 |
|
58 |
38 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
272 |
256 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
459 |
112 |
$2K |
| D1120 |
Prophylaxis - child |
29 |
29 |
$1K |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$336.00 |
| D1310 |
|
16 |
16 |
$0.00 |