| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
583 |
296 |
$277K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
845 |
842 |
$55K |
| D1110 |
Prophylaxis - adult |
583 |
581 |
$50K |
| D9110 |
|
764 |
601 |
$48K |
| D2954 |
|
428 |
229 |
$45K |
| D2332 |
|
418 |
72 |
$35K |
| D0210 |
Intraoral - complete series of radiographic images |
717 |
714 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
434 |
212 |
$29K |
| D4910 |
|
327 |
323 |
$25K |
| D3320 |
|
56 |
37 |
$20K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
258 |
127 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
207 |
202 |
$14K |
| D4341 |
|
187 |
51 |
$13K |
| D2335 |
|
87 |
26 |
$10K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
20 |
14 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
169 |
76 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,244 |
759 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
503 |
501 |
$7K |
| D2394 |
|
41 |
26 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
242 |
222 |
$3K |
| D0274 |
Bitewings - four radiographic images |
118 |
118 |
$2K |
| D1120 |
Prophylaxis - child |
39 |
39 |
$2K |
| D9430 |
|
21 |
17 |
$608.00 |