| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
1,300 |
794 |
$618K |
| D0120 |
Periodic oral evaluation - established patient |
7,932 |
7,911 |
$440K |
| D1110 |
Prophylaxis - adult |
3,514 |
3,501 |
$300K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
591 |
476 |
$274K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
2,302 |
1,401 |
$272K |
| D1120 |
Prophylaxis - child |
6,029 |
6,017 |
$228K |
| D2954 |
|
2,063 |
1,235 |
$216K |
| D0230 |
Intraoral - periapical each additional radiographic image |
48,125 |
8,891 |
$195K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,017 |
3,015 |
$191K |
| D4341 |
|
1,993 |
542 |
$136K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,230 |
1,156 |
$127K |
| D0210 |
Intraoral - complete series of radiographic images |
2,683 |
2,682 |
$126K |
| D1351 |
Sealant - per tooth |
4,329 |
1,101 |
$119K |
| D3320 |
|
305 |
216 |
$111K |
| D0350 |
|
10,584 |
5,250 |
$95K |
| D0272 |
Bitewings - two radiographic images |
6,910 |
6,891 |
$81K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,103 |
653 |
$74K |
| D4910 |
|
911 |
910 |
$70K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,708 |
5,697 |
$66K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
811 |
399 |
$54K |
| D2931 |
|
309 |
203 |
$39K |
| D0220 |
Intraoral - periapical first radiographic image |
3,037 |
2,992 |
$36K |
| D9993 |
|
278 |
277 |
$17K |
| D3310 |
|
49 |
37 |
$15K |
| D1310 |
|
277 |
276 |
$12K |
| D0330 |
Panoramic radiographic image |
347 |
347 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
87 |
37 |
$9K |
| D3221 |
|
102 |
93 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
117 |
79 |
$6K |
| D2140 |
|
88 |
56 |
$5K |
| D2330 |
|
44 |
27 |
$3K |
| D4342 |
|
71 |
25 |
$3K |
| D9430 |
|
88 |
87 |
$3K |
| D2160 |
|
18 |
12 |
$1K |
| D0603 |
|
91 |
89 |
$804.00 |