| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
876 |
597 |
$414K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,851 |
981 |
$121K |
| D2952 |
|
915 |
685 |
$95K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,461 |
1,451 |
$93K |
| D1110 |
Prophylaxis - adult |
1,033 |
1,028 |
$90K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
171 |
150 |
$76K |
| D0120 |
Periodic oral evaluation - established patient |
1,062 |
1,062 |
$69K |
| D2740 |
Crown - porcelain/ceramic |
139 |
90 |
$66K |
| D0210 |
Intraoral - complete series of radiographic images |
1,263 |
1,255 |
$59K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,066 |
518 |
$57K |
| D0350 |
|
5,036 |
1,906 |
$53K |
| D1120 |
Prophylaxis - child |
1,185 |
1,182 |
$52K |
| D1206 |
Topical application of fluoride varnish |
2,686 |
2,676 |
$39K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
311 |
199 |
$24K |
| D0274 |
Bitewings - four radiographic images |
583 |
583 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,892 |
1,294 |
$12K |
| D4910 |
|
95 |
95 |
$7K |
| D3320 |
|
17 |
13 |
$6K |
| D9430 |
|
179 |
174 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
37 |
12 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
184 |
179 |
$2K |
| D0272 |
Bitewings - two radiographic images |
19 |
19 |
$228.00 |