| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
1,013 |
669 |
$480K |
| D0120 |
Periodic oral evaluation - established patient |
7,589 |
7,587 |
$435K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
677 |
613 |
$310K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,840 |
4,832 |
$300K |
| D1120 |
Prophylaxis - child |
7,575 |
7,561 |
$285K |
| D1110 |
Prophylaxis - adult |
2,988 |
2,984 |
$248K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
2,138 |
1,135 |
$247K |
| D0210 |
Intraoral - complete series of radiographic images |
4,924 |
4,919 |
$225K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
3,337 |
1,269 |
$222K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,793 |
1,111 |
$185K |
| D0230 |
Intraoral - periapical each additional radiographic image |
44,034 |
7,831 |
$181K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,692 |
1,071 |
$144K |
| D2954 |
|
1,195 |
814 |
$125K |
| D1208 |
Topical application of fluoride, excluding varnish |
10,877 |
10,866 |
$124K |
| D2160 |
|
1,497 |
747 |
$118K |
| D0274 |
Bitewings - four radiographic images |
4,670 |
4,667 |
$99K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
171 |
116 |
$80K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,321 |
526 |
$75K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
917 |
470 |
$72K |
| D0330 |
Panoramic radiographic image |
2,229 |
2,223 |
$65K |
| D2330 |
|
646 |
344 |
$48K |
| D0350 |
|
4,572 |
2,023 |
$45K |
| D2140 |
|
682 |
315 |
$37K |
| D4341 |
|
436 |
114 |
$30K |
| D0272 |
Bitewings - two radiographic images |
2,457 |
2,454 |
$29K |
| D3320 |
|
80 |
62 |
$29K |
| D1310 |
|
622 |
618 |
$27K |
| D1351 |
Sealant - per tooth |
1,232 |
374 |
$26K |
| D9993 |
|
370 |
370 |
$23K |
| D4910 |
|
149 |
149 |
$11K |
| D3310 |
|
24 |
12 |
$7K |
| D0603 |
|
143 |
141 |
$2K |
| D9430 |
|
45 |
45 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
94 |
94 |
$1K |
| D0601 |
|
29 |
29 |
$416.25 |
| D0270 |
|
30 |
30 |
$150.00 |