| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
849 |
785 |
$405K |
| D1110 |
Prophylaxis - adult |
5,779 |
5,779 |
$250K |
| D2954 |
|
1,049 |
999 |
$125K |
| D0120 |
Periodic oral evaluation - established patient |
5,213 |
5,213 |
$115K |
| D0274 |
Bitewings - four radiographic images |
4,388 |
4,388 |
$97K |
| D0220 |
Intraoral - periapical first radiographic image |
6,161 |
6,135 |
$66K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
199 |
199 |
$61K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
470 |
413 |
$42K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,737 |
4,730 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
551 |
490 |
$35K |
| D3320 |
|
65 |
65 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
564 |
564 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
550 |
550 |
$6K |
| D2791 |
|
13 |
13 |
$5K |
| D9310 |
|
69 |
69 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
136 |
136 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
28 |
24 |
$3K |
| D9110 |
|
87 |
87 |
$2K |
| D2330 |
|
13 |
13 |
$1K |
| D1999 |
|
351 |
296 |
$0.00 |