| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
991 |
483 |
$471K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,220 |
4,206 |
$268K |
| D1110 |
Prophylaxis - adult |
2,492 |
2,481 |
$215K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
436 |
336 |
$202K |
| D1351 |
Sealant - per tooth |
5,978 |
1,273 |
$171K |
| D0120 |
Periodic oral evaluation - established patient |
2,503 |
2,503 |
$142K |
| D1120 |
Prophylaxis - child |
3,474 |
3,464 |
$132K |
| D0230 |
Intraoral - periapical each additional radiographic image |
25,061 |
5,152 |
$107K |
| D2952 |
|
1,014 |
501 |
$106K |
| D0210 |
Intraoral - complete series of radiographic images |
2,113 |
2,107 |
$100K |
| D4341 |
|
1,432 |
378 |
$98K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,985 |
5,965 |
$79K |
| D0274 |
Bitewings - four radiographic images |
3,425 |
3,419 |
$72K |
| D3320 |
|
179 |
111 |
$65K |
| D9430 |
|
1,970 |
1,753 |
$63K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
946 |
309 |
$62K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,049 |
230 |
$57K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
768 |
255 |
$51K |
| D3310 |
|
146 |
60 |
$44K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
486 |
202 |
$38K |
| D0330 |
Panoramic radiographic image |
1,135 |
1,129 |
$33K |
| D0220 |
Intraoral - periapical first radiographic image |
1,799 |
1,770 |
$21K |
| D1320 |
|
1,334 |
1,333 |
$21K |
| D0350 |
|
1,994 |
551 |
$21K |
| D2140 |
|
413 |
123 |
$21K |
| D4910 |
|
245 |
245 |
$19K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
170 |
62 |
$18K |
| D2160 |
|
136 |
71 |
$11K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
82 |
13 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
90 |
14 |
$9K |
| D1310 |
|
137 |
135 |
$6K |
| D4342 |
|
79 |
27 |
$3K |
| D0602 |
|
151 |
149 |
$2K |
| D9993 |
|
137 |
134 |
$1K |
| D2330 |
|
22 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
48 |
48 |
$536.00 |