| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
880 |
474 |
$595K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
306 |
157 |
$191K |
| D1351 |
Sealant - per tooth |
5,279 |
472 |
$160K |
| D2954 |
|
736 |
437 |
$155K |
| D3320 |
|
267 |
199 |
$135K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
173 |
157 |
$109K |
| D1110 |
Prophylaxis - adult |
2,402 |
2,386 |
$107K |
| D0120 |
Periodic oral evaluation - established patient |
4,059 |
4,035 |
$98K |
| D0140 |
Limited oral evaluation - problem focused |
3,048 |
2,890 |
$97K |
| D0274 |
Bitewings - four radiographic images |
3,622 |
3,598 |
$95K |
| D4355 |
|
1,304 |
1,294 |
$93K |
| D2950 |
|
517 |
344 |
$89K |
| D0330 |
Panoramic radiographic image |
1,446 |
1,440 |
$79K |
| D0220 |
Intraoral - periapical first radiographic image |
5,835 |
5,649 |
$76K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
486 |
292 |
$75K |
| D3310 |
|
147 |
71 |
$61K |
| D2722 |
|
110 |
60 |
$60K |
| D1120 |
Prophylaxis - child |
1,322 |
1,321 |
$54K |
| D4341 |
|
341 |
90 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,308 |
1,304 |
$48K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,948 |
1,947 |
$46K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,449 |
5,307 |
$42K |
| D7140 |
Extraction, erupted tooth or exposed root |
370 |
250 |
$32K |
| D5213 |
|
13 |
13 |
$13K |
| D5214 |
|
12 |
12 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
151 |
95 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
92 |
53 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
65 |
29 |
$4K |
| D1510 |
|
16 |
12 |
$3K |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$550.00 |