| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
1,213 |
604 |
$575K |
| D2954 |
|
1,623 |
866 |
$169K |
| D9951 |
|
4,845 |
1,987 |
$162K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
322 |
269 |
$147K |
| D4910 |
|
1,670 |
1,662 |
$124K |
| D2330 |
|
1,557 |
886 |
$120K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,705 |
808 |
$113K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,099 |
1,142 |
$112K |
| D4341 |
|
1,592 |
438 |
$110K |
| D3320 |
|
295 |
208 |
$107K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,502 |
1,494 |
$98K |
| D1110 |
Prophylaxis - adult |
1,093 |
1,092 |
$94K |
| D3221 |
|
1,490 |
791 |
$92K |
| D4260 |
|
160 |
46 |
$78K |
| D0210 |
Intraoral - complete series of radiographic images |
1,460 |
1,452 |
$68K |
| D9430 |
|
1,533 |
1,513 |
$49K |
| D2931 |
|
280 |
185 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
457 |
455 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
2,511 |
2,442 |
$30K |
| D3310 |
|
98 |
41 |
$30K |
| D9910 |
|
409 |
408 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,408 |
1,405 |
$19K |
| D5851 |
|
222 |
220 |
$15K |
| D5850 |
|
181 |
181 |
$12K |
| D5422 |
|
370 |
300 |
$12K |
| D2920 |
|
272 |
271 |
$11K |
| D5421 |
|
239 |
193 |
$8K |
| D4342 |
|
164 |
59 |
$7K |
| D5660 |
|
32 |
29 |
$4K |
| D6930 |
|
57 |
57 |
$4K |
| D1120 |
Prophylaxis - child |
87 |
87 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
36 |
25 |
$3K |
| D5761 |
|
12 |
12 |
$2K |
| D5630 |
|
12 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
315 |
125 |
$1K |
| D0350 |
|
375 |
102 |
$1K |
| D0330 |
Panoramic radiographic image |
37 |
36 |
$1K |
| D0274 |
Bitewings - four radiographic images |
50 |
50 |
$1K |
| D5612 |
|
13 |
13 |
$924.00 |