| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
340 |
220 |
$162K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
639 |
631 |
$42K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
364 |
183 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
447 |
181 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
391 |
383 |
$18K |
| D1110 |
Prophylaxis - adult |
114 |
114 |
$10K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
13 |
13 |
$6K |
| D0274 |
Bitewings - four radiographic images |
232 |
231 |
$5K |
| D2952 |
|
43 |
28 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
319 |
243 |
$4K |
| D1320 |
|
171 |
171 |
$3K |