| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
2,579 |
1,239 |
$1.23M |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
801 |
708 |
$371K |
| D1110 |
Prophylaxis - adult |
4,148 |
4,140 |
$340K |
| D4341 |
|
4,466 |
1,255 |
$305K |
| D3320 |
|
654 |
511 |
$239K |
| D2952 |
|
2,229 |
1,123 |
$234K |
| D0120 |
Periodic oral evaluation - established patient |
3,605 |
3,600 |
$200K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,787 |
2,785 |
$176K |
| D3310 |
|
577 |
281 |
$174K |
| D0210 |
Intraoral - complete series of radiographic images |
2,720 |
2,718 |
$126K |
| D4910 |
|
1,491 |
1,491 |
$115K |
| D4342 |
|
2,356 |
765 |
$97K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,599 |
3,583 |
$73K |
| D1206 |
Topical application of fluoride varnish |
4,327 |
4,323 |
$69K |
| D1120 |
Prophylaxis - child |
1,468 |
1,463 |
$55K |
| D2954 |
|
434 |
255 |
$45K |
| D0274 |
Bitewings - four radiographic images |
1,973 |
1,970 |
$42K |
| D1351 |
Sealant - per tooth |
1,347 |
302 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
472 |
341 |
$32K |
| D0220 |
Intraoral - periapical first radiographic image |
2,247 |
2,209 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
397 |
113 |
$22K |
| D2330 |
|
131 |
26 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
46 |
38 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
21 |
14 |
$2K |
| D9951 |
|
27 |
27 |
$945.00 |
| D0272 |
Bitewings - two radiographic images |
81 |
80 |
$906.00 |