| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
707 |
526 |
$336K |
| D0120 |
Periodic oral evaluation - established patient |
2,573 |
2,565 |
$188K |
| D1110 |
Prophylaxis - adult |
1,944 |
1,938 |
$167K |
| D9910 |
|
2,559 |
2,533 |
$152K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,174 |
2,167 |
$143K |
| D1120 |
Prophylaxis - child |
2,375 |
2,369 |
$104K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,839 |
1,070 |
$99K |
| D2330 |
|
1,189 |
648 |
$90K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,219 |
880 |
$81K |
| D0230 |
Intraoral - periapical each additional radiographic image |
18,712 |
3,786 |
$77K |
| D4910 |
|
974 |
974 |
$75K |
| D2954 |
|
657 |
510 |
$69K |
| D4341 |
|
896 |
251 |
$63K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
132 |
121 |
$61K |
| D0210 |
Intraoral - complete series of radiographic images |
1,223 |
1,219 |
$58K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,577 |
4,562 |
$58K |
| D1351 |
Sealant - per tooth |
1,837 |
456 |
$57K |
| D0274 |
Bitewings - four radiographic images |
2,341 |
2,333 |
$49K |
| D9430 |
|
1,431 |
1,361 |
$46K |
| D0340 |
|
916 |
912 |
$46K |
| D0330 |
Panoramic radiographic image |
1,272 |
1,268 |
$37K |
| D2332 |
|
318 |
172 |
$28K |
| D1320 |
|
1,798 |
1,785 |
$27K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
375 |
270 |
$25K |
| D3320 |
|
61 |
53 |
$22K |
| D9110 |
|
318 |
256 |
$20K |
| D2331 |
|
227 |
141 |
$18K |
| D2140 |
|
249 |
148 |
$13K |
| D3221 |
|
117 |
98 |
$7K |
| D0272 |
Bitewings - two radiographic images |
550 |
548 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
113 |
52 |
$6K |
| D0350 |
|
620 |
291 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
57 |
43 |
$4K |
| D2160 |
|
31 |
25 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
191 |
187 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
19 |
15 |
$2K |
| D1310 |
|
12 |
12 |
$506.00 |
| D0603 |
|
12 |
12 |
$165.00 |
| D1999 |
|
17 |
17 |
$0.00 |