| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
905 |
526 |
$427K |
| D1110 |
Prophylaxis - adult |
4,918 |
4,896 |
$410K |
| D0120 |
Periodic oral evaluation - established patient |
7,796 |
7,787 |
$403K |
| D4341 |
|
4,787 |
1,385 |
$316K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
4,363 |
2,454 |
$290K |
| D1120 |
Prophylaxis - child |
6,502 |
6,492 |
$241K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,856 |
3,842 |
$240K |
| D0230 |
Intraoral - periapical each additional radiographic image |
63,958 |
9,461 |
$235K |
| D1351 |
Sealant - per tooth |
8,407 |
2,574 |
$229K |
| D7140 |
Extraction, erupted tooth or exposed root |
4,065 |
1,555 |
$228K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,937 |
1,102 |
$225K |
| D4910 |
|
2,291 |
2,284 |
$174K |
| D1208 |
Topical application of fluoride, excluding varnish |
11,413 |
11,380 |
$144K |
| D0274 |
Bitewings - four radiographic images |
5,694 |
5,681 |
$119K |
| D2140 |
|
2,200 |
1,470 |
$119K |
| D0210 |
Intraoral - complete series of radiographic images |
2,419 |
2,404 |
$113K |
| D2335 |
|
845 |
518 |
$94K |
| D3320 |
|
245 |
211 |
$89K |
| D2160 |
|
1,041 |
784 |
$83K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,083 |
622 |
$71K |
| D2954 |
|
652 |
467 |
$68K |
| D0350 |
|
7,610 |
3,669 |
$67K |
| D9993 |
|
552 |
536 |
$33K |
| D0220 |
Intraoral - periapical first radiographic image |
2,658 |
2,579 |
$31K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
349 |
253 |
$28K |
| D2931 |
|
214 |
185 |
$27K |
| D1310 |
|
614 |
592 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
492 |
348 |
$26K |
| D3310 |
|
85 |
50 |
$26K |
| D0272 |
Bitewings - two radiographic images |
2,189 |
2,185 |
$25K |
| D9430 |
|
727 |
707 |
$23K |
| D7240 |
Removal of impacted tooth - completely bony |
95 |
50 |
$22K |
| D2330 |
|
287 |
185 |
$21K |
| D4342 |
|
480 |
172 |
$19K |
| D5750 |
|
60 |
59 |
$12K |
| D5850 |
|
111 |
111 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
68 |
41 |
$7K |
| D5751 |
|
27 |
27 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
47 |
27 |
$5K |
| D0603 |
|
207 |
198 |
$3K |
| D5851 |
|
42 |
42 |
$3K |
| D1354 |
|
96 |
41 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$826.00 |
| D0602 |
|
15 |
15 |
$210.00 |