| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
308 |
186 |
$120K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
111 |
82 |
$83K |
| D1110 |
Prophylaxis - adult |
1,266 |
1,256 |
$77K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
573 |
281 |
$73K |
| D0140 |
Limited oral evaluation - problem focused |
1,288 |
1,119 |
$57K |
| D1206 |
Topical application of fluoride varnish |
2,217 |
2,191 |
$55K |
| D3320 |
|
75 |
57 |
$48K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
854 |
847 |
$45K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
262 |
115 |
$41K |
| D2950 |
|
446 |
241 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,208 |
1,190 |
$35K |
| D2750 |
|
84 |
40 |
$31K |
| D1120 |
Prophylaxis - child |
647 |
636 |
$29K |
| D1351 |
Sealant - per tooth |
734 |
98 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
2,192 |
1,977 |
$22K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
184 |
63 |
$16K |
| D0274 |
Bitewings - four radiographic images |
622 |
617 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
228 |
225 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,527 |
1,397 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
118 |
65 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
78 |
39 |
$10K |
| D9910 |
|
986 |
971 |
$10K |
| D2740 |
Crown - porcelain/ceramic |
16 |
12 |
$5K |
| D1330 |
|
723 |
718 |
$5K |
| D2332 |
|
33 |
12 |
$4K |
| D0330 |
Panoramic radiographic image |
93 |
93 |
$4K |
| D4355 |
|
12 |
12 |
$1K |
| D3120 |
|
13 |
12 |
$422.60 |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$345.00 |
| D0460 |
|
31 |
27 |
$310.00 |