| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
1,465 |
921 |
$670K |
| D0120 |
Periodic oral evaluation - established patient |
9,633 |
9,632 |
$196K |
| D1110 |
Prophylaxis - adult |
5,146 |
5,146 |
$196K |
| D0274 |
Bitewings - four radiographic images |
7,928 |
7,928 |
$168K |
| D0210 |
Intraoral - complete series of radiographic images |
6,936 |
6,931 |
$129K |
| D1120 |
Prophylaxis - child |
3,783 |
3,783 |
$109K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,709 |
3,709 |
$101K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,006 |
974 |
$83K |
| D0220 |
Intraoral - periapical first radiographic image |
7,357 |
7,343 |
$77K |
| D2954 |
|
639 |
466 |
$68K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,781 |
5,781 |
$61K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,141 |
6,140 |
$51K |
| D1351 |
Sealant - per tooth |
389 |
363 |
$38K |
| D3320 |
|
171 |
145 |
$33K |
| D0330 |
Panoramic radiographic image |
1,459 |
1,459 |
$32K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
456 |
417 |
$32K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
254 |
242 |
$27K |
| D8670 |
Periodic orthodontic treatment visit |
149 |
149 |
$26K |
| D4341 |
|
263 |
150 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
1,299 |
1,296 |
$13K |
| D2952 |
|
104 |
101 |
$13K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
28 |
27 |
$8K |
| D0272 |
Bitewings - two radiographic images |
560 |
560 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
43 |
$3K |
| D2140 |
|
71 |
66 |
$3K |
| D2160 |
|
12 |
12 |
$1K |
| D1354 |
|
13 |
13 |
$825.00 |
| D8660 |
|
26 |
26 |
$754.00 |
| D9310 |
|
15 |
15 |
$708.75 |
| D0340 |
|
12 |
12 |
$542.30 |
| D4910 |
|
12 |
12 |
$464.72 |
| D1206 |
Topical application of fluoride varnish |
18 |
18 |
$430.44 |
| D0470 |
|
12 |
12 |
$367.20 |
| D0350 |
|
12 |
12 |
$142.80 |
| D1999 |
|
286 |
286 |
$0.00 |