| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
796 |
622 |
$379K |
| D0120 |
Periodic oral evaluation - established patient |
4,752 |
4,731 |
$278K |
| D0350 |
|
28,891 |
7,940 |
$274K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,289 |
4,259 |
$273K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,810 |
1,998 |
$254K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
4,039 |
1,978 |
$217K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,585 |
844 |
$187K |
| D0210 |
Intraoral - complete series of radiographic images |
3,218 |
3,187 |
$152K |
| D0230 |
Intraoral - periapical each additional radiographic image |
34,965 |
7,235 |
$141K |
| D1120 |
Prophylaxis - child |
3,688 |
3,667 |
$140K |
| D4341 |
|
1,808 |
545 |
$126K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
272 |
239 |
$126K |
| D9430 |
|
2,896 |
2,807 |
$89K |
| D0274 |
Bitewings - four radiographic images |
3,563 |
3,547 |
$73K |
| D4910 |
|
870 |
870 |
$66K |
| D1351 |
Sealant - per tooth |
1,647 |
463 |
$45K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,409 |
3,391 |
$38K |
| D2952 |
|
351 |
287 |
$37K |
| D7140 |
Extraction, erupted tooth or exposed root |
611 |
287 |
$34K |
| D8670 |
Periodic orthodontic treatment visit |
117 |
117 |
$31K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
275 |
97 |
$31K |
| D0330 |
Panoramic radiographic image |
1,026 |
1,014 |
$22K |
| D1310 |
|
418 |
418 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
202 |
149 |
$16K |
| D1110 |
Prophylaxis - adult |
186 |
186 |
$16K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
159 |
53 |
$16K |
| D0272 |
Bitewings - two radiographic images |
1,351 |
1,344 |
$16K |
| D2330 |
|
176 |
87 |
$13K |
| D4342 |
|
313 |
98 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,067 |
1,040 |
$13K |
| D1206 |
Topical application of fluoride varnish |
641 |
634 |
$11K |
| D9993 |
|
128 |
128 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
191 |
183 |
$5K |
| D7230 |
|
27 |
13 |
$5K |
| D3320 |
|
13 |
12 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
127 |
122 |
$3K |
| D2335 |
|
22 |
13 |
$3K |
| D0270 |
|
439 |
432 |
$2K |
| D0601 |
|
61 |
61 |
$915.00 |
| D0340 |
|
13 |
13 |
$650.00 |
| D0603 |
|
28 |
28 |
$420.00 |
| D0602 |
|
13 |
13 |
$195.00 |