| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
524 |
304 |
$185K |
| D1110 |
Prophylaxis - adult |
4,602 |
4,598 |
$167K |
| D0120 |
Periodic oral evaluation - established patient |
4,335 |
4,331 |
$87K |
| D0274 |
Bitewings - four radiographic images |
3,565 |
3,565 |
$69K |
| D2954 |
|
691 |
484 |
$62K |
| D0220 |
Intraoral - periapical first radiographic image |
4,943 |
4,936 |
$45K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
604 |
432 |
$40K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,912 |
4,894 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
830 |
830 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
573 |
570 |
$14K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
39 |
37 |
$11K |
| D2332 |
|
135 |
102 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
104 |
84 |
$7K |
| D0272 |
Bitewings - two radiographic images |
453 |
453 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
79 |
65 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
457 |
457 |
$5K |
| D1120 |
Prophylaxis - child |
126 |
126 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
54 |
40 |
$3K |
| D3320 |
|
16 |
12 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
39 |
28 |
$2K |
| D4249 |
|
14 |
14 |
$2K |