| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
1,021 |
782 |
$472K |
| D1110 |
Prophylaxis - adult |
7,375 |
7,309 |
$308K |
| D0210 |
Intraoral - complete series of radiographic images |
5,523 |
5,433 |
$293K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
3,790 |
1,621 |
$284K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,245 |
2,161 |
$244K |
| D0120 |
Periodic oral evaluation - established patient |
10,343 |
10,211 |
$206K |
| D1208 |
Topical application of fluoride, excluding varnish |
9,587 |
9,528 |
$142K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
280 |
243 |
$140K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,644 |
5,478 |
$128K |
| D1351 |
Sealant - per tooth |
6,784 |
1,080 |
$126K |
| D1120 |
Prophylaxis - child |
4,334 |
4,316 |
$113K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,208 |
881 |
$105K |
| D2954 |
|
778 |
603 |
$99K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,474 |
1,019 |
$81K |
| D0220 |
Intraoral - periapical first radiographic image |
8,821 |
8,537 |
$60K |
| D0274 |
Bitewings - four radiographic images |
3,382 |
3,310 |
$60K |
| D0140 |
Limited oral evaluation - problem focused |
2,597 |
2,542 |
$52K |
| D4341 |
|
545 |
222 |
$48K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,980 |
6,173 |
$31K |
| D7140 |
Extraction, erupted tooth or exposed root |
539 |
187 |
$19K |
| D9310 |
|
629 |
624 |
$14K |
| D4910 |
|
211 |
202 |
$12K |
| D3320 |
|
30 |
24 |
$11K |
| D0272 |
Bitewings - two radiographic images |
842 |
842 |
$11K |
| D0330 |
Panoramic radiographic image |
268 |
263 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
585 |
504 |
$7K |
| D2332 |
|
87 |
63 |
$7K |
| D0270 |
|
926 |
898 |
$7K |
| D2950 |
|
89 |
68 |
$5K |
| D4355 |
|
104 |
101 |
$5K |
| D0602 |
|
460 |
460 |
$4K |
| D1353 |
|
377 |
112 |
$4K |
| D9920 |
|
147 |
146 |
$2K |
| D9430 |
|
177 |
163 |
$2K |
| D2335 |
|
21 |
12 |
$2K |
| D0601 |
|
184 |
184 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
17 |
13 |
$2K |
| D3240 |
|
15 |
12 |
$2K |
| D3331 |
|
15 |
13 |
$750.00 |
| D1206 |
Topical application of fluoride varnish |
58 |
58 |
$480.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
25 |
25 |
$345.00 |
| D0350 |
|
104 |
104 |
$272.00 |
| D9910 |
|
74 |
48 |
$190.00 |
| D0603 |
|
13 |
13 |
$90.00 |