| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
1,458 |
715 |
$693K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
423 |
371 |
$196K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,250 |
2,238 |
$145K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
959 |
460 |
$110K |
| D2954 |
|
1,040 |
498 |
$108K |
| D1110 |
Prophylaxis - adult |
1,209 |
1,204 |
$100K |
| D0210 |
Intraoral - complete series of radiographic images |
2,041 |
2,034 |
$96K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
996 |
524 |
$79K |
| D3348 |
|
167 |
133 |
$77K |
| D3320 |
|
174 |
137 |
$63K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
636 |
322 |
$41K |
| D4341 |
|
579 |
152 |
$40K |
| D3347 |
|
95 |
67 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
501 |
501 |
$27K |
| D1206 |
Topical application of fluoride varnish |
1,446 |
1,442 |
$22K |
| D3221 |
|
374 |
245 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,488 |
785 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
250 |
134 |
$14K |
| D4910 |
|
126 |
126 |
$10K |
| D2952 |
|
77 |
60 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
632 |
574 |
$8K |
| D0274 |
Bitewings - four radiographic images |
315 |
314 |
$6K |
| D1120 |
Prophylaxis - child |
182 |
182 |
$6K |
| D3310 |
|
18 |
12 |
$5K |
| D9430 |
|
93 |
90 |
$3K |
| D2931 |
|
16 |
12 |
$2K |
| D2330 |
|
25 |
12 |
$2K |
| D4342 |
|
35 |
13 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
151 |
149 |
$1K |