| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
490 |
353 |
$232K |
| D1110 |
Prophylaxis - adult |
2,034 |
2,030 |
$169K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
310 |
266 |
$142K |
| D0230 |
Intraoral - periapical each additional radiographic image |
29,209 |
4,187 |
$109K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,316 |
716 |
$88K |
| D0120 |
Periodic oral evaluation - established patient |
1,672 |
1,668 |
$87K |
| D0274 |
Bitewings - four radiographic images |
3,027 |
3,020 |
$61K |
| D2954 |
|
502 |
365 |
$53K |
| D1120 |
Prophylaxis - child |
1,450 |
1,448 |
$49K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
826 |
825 |
$48K |
| D9430 |
|
1,417 |
1,373 |
$45K |
| D4341 |
|
571 |
203 |
$36K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
452 |
302 |
$36K |
| D7140 |
Extraction, erupted tooth or exposed root |
466 |
239 |
$27K |
| D3320 |
|
72 |
56 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
367 |
208 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,158 |
1,135 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
252 |
252 |
$11K |
| D4910 |
|
125 |
120 |
$9K |
| D3310 |
|
25 |
14 |
$8K |
| D0350 |
|
578 |
278 |
$6K |
| D4342 |
|
38 |
15 |
$2K |
| D0270 |
|
240 |
205 |
$1K |