| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
1,076 |
774 |
$512K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
2,925 |
1,355 |
$339K |
| D0120 |
Periodic oral evaluation - established patient |
4,707 |
4,679 |
$271K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,865 |
3,851 |
$246K |
| D1120 |
Prophylaxis - child |
5,109 |
5,080 |
$201K |
| D1110 |
Prophylaxis - adult |
1,877 |
1,866 |
$153K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,076 |
1,124 |
$137K |
| D0210 |
Intraoral - complete series of radiographic images |
2,988 |
2,973 |
$135K |
| D9430 |
|
3,476 |
3,369 |
$109K |
| D2954 |
|
1,055 |
761 |
$105K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,578 |
881 |
$105K |
| D0230 |
Intraoral - periapical each additional radiographic image |
17,969 |
7,739 |
$105K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,181 |
7,138 |
$92K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,504 |
783 |
$81K |
| D4341 |
|
1,065 |
290 |
$74K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
150 |
140 |
$66K |
| D0274 |
Bitewings - four radiographic images |
3,136 |
3,122 |
$66K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
777 |
483 |
$62K |
| D0350 |
|
4,557 |
1,978 |
$60K |
| D0220 |
Intraoral - periapical first radiographic image |
5,066 |
4,959 |
$59K |
| D4910 |
|
455 |
454 |
$34K |
| D1310 |
|
576 |
575 |
$24K |
| D1351 |
Sealant - per tooth |
675 |
153 |
$24K |
| D2330 |
|
205 |
114 |
$15K |
| D2332 |
|
153 |
103 |
$12K |
| D0330 |
Panoramic radiographic image |
375 |
369 |
$11K |
| D2335 |
|
93 |
52 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
170 |
71 |
$10K |
| D2140 |
|
163 |
89 |
$9K |
| D7230 |
|
43 |
40 |
$8K |
| D2331 |
|
79 |
48 |
$6K |
| D2160 |
|
67 |
53 |
$5K |
| D2394 |
|
62 |
42 |
$5K |
| D0601 |
|
312 |
311 |
$3K |
| D9993 |
|
180 |
180 |
$2K |
| D0602 |
|
16 |
16 |
$15.00 |
| D1999 |
|
236 |
221 |
$10.00 |