| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
568 |
453 |
$246K |
| D1110 |
Prophylaxis - adult |
2,205 |
2,204 |
$95K |
| D2954 |
|
396 |
343 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,859 |
1,858 |
$41K |
| D0274 |
Bitewings - four radiographic images |
1,648 |
1,648 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
2,094 |
2,087 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,934 |
1,933 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
282 |
165 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
113 |
75 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
274 |
274 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
349 |
349 |
$4K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
12 |
12 |
$4K |
| D3320 |
|
14 |
13 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
133 |
133 |
$3K |