| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
727 |
469 |
$370K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
170 |
150 |
$82K |
| D1351 |
Sealant - per tooth |
2,753 |
287 |
$66K |
| D2954 |
|
651 |
445 |
$63K |
| D1110 |
Prophylaxis - adult |
2,256 |
2,173 |
$61K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
874 |
462 |
$44K |
| D0210 |
Intraoral - complete series of radiographic images |
1,120 |
1,085 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,572 |
1,533 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
1,292 |
1,241 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,114 |
2,044 |
$27K |
| D0330 |
Panoramic radiographic image |
1,187 |
1,148 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
788 |
767 |
$21K |
| D1120 |
Prophylaxis - child |
632 |
627 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
258 |
141 |
$15K |
| D3320 |
|
40 |
29 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
256 |
114 |
$14K |
| D1206 |
Topical application of fluoride varnish |
669 |
661 |
$13K |
| D0274 |
Bitewings - four radiographic images |
1,293 |
1,252 |
$13K |
| D4341 |
|
210 |
75 |
$10K |
| D3310 |
|
31 |
12 |
$9K |
| D9920 |
|
469 |
464 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
83 |
40 |
$6K |
| D7311 |
|
51 |
14 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
71 |
41 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
505 |
476 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
236 |
171 |
$1K |
| D0601 |
|
165 |
162 |
$1K |
| D2394 |
|
19 |
12 |
$1K |
| D2950 |
|
19 |
12 |
$1K |
| D4910 |
|
12 |
12 |
$670.00 |
| D0603 |
|
40 |
39 |
$330.00 |
| D0602 |
|
24 |
24 |
$230.00 |
| D1330 |
|
159 |
158 |
$0.00 |