| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
347 |
194 |
$165K |
| D4341 |
|
1,672 |
446 |
$117K |
| D2954 |
|
531 |
319 |
$55K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
94 |
87 |
$43K |
| D1110 |
Prophylaxis - adult |
506 |
505 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
593 |
592 |
$39K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
353 |
191 |
$37K |
| D2740 |
Crown - porcelain/ceramic |
76 |
46 |
$36K |
| D3310 |
|
94 |
49 |
$28K |
| D3320 |
|
60 |
58 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,942 |
539 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
145 |
107 |
$11K |
| D5110 |
|
18 |
18 |
$11K |
| D5120 |
|
17 |
17 |
$11K |
| D0274 |
Bitewings - four radiographic images |
486 |
485 |
$10K |
| D2394 |
|
79 |
68 |
$7K |
| D5750 |
|
13 |
13 |
$3K |
| D4342 |
|
22 |
12 |
$924.00 |
| D5410 |
|
13 |
13 |
$455.00 |