| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
1,685 |
1,054 |
$801K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
890 |
752 |
$408K |
| D2954 |
|
2,466 |
1,671 |
$254K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,261 |
2,257 |
$141K |
| D0120 |
Periodic oral evaluation - established patient |
2,623 |
2,617 |
$134K |
| D1110 |
Prophylaxis - adult |
1,437 |
1,431 |
$121K |
| D0274 |
Bitewings - four radiographic images |
3,007 |
3,003 |
$61K |
| D0230 |
Intraoral - periapical each additional radiographic image |
15,397 |
3,655 |
$60K |
| D1120 |
Prophylaxis - child |
1,129 |
1,129 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,103 |
2,098 |
$27K |
| D3320 |
|
69 |
56 |
$25K |
| D4341 |
|
347 |
105 |
$24K |
| D2931 |
|
183 |
154 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
369 |
112 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
210 |
95 |
$14K |
| D4910 |
|
177 |
175 |
$14K |
| D9430 |
|
326 |
310 |
$10K |
| D3310 |
|
21 |
12 |
$6K |
| D1351 |
Sealant - per tooth |
294 |
71 |
$6K |
| D1206 |
Topical application of fluoride varnish |
372 |
372 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
77 |
75 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
33 |
13 |
$2K |
| D4342 |
|
37 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
101 |
99 |
$985.00 |
| D0270 |
|
12 |
12 |
$60.00 |