| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
1,303 |
791 |
$457K |
| D1110 |
Prophylaxis - adult |
5,406 |
5,214 |
$127K |
| D0120 |
Periodic oral evaluation - established patient |
5,166 |
4,976 |
$120K |
| D2740 |
Crown - porcelain/ceramic |
262 |
161 |
$105K |
| D2954 |
|
1,149 |
766 |
$85K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
229 |
180 |
$82K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,441 |
843 |
$67K |
| D0140 |
Limited oral evaluation - problem focused |
2,368 |
2,254 |
$56K |
| D1351 |
Sealant - per tooth |
1,758 |
166 |
$43K |
| D0330 |
Panoramic radiographic image |
1,482 |
1,433 |
$43K |
| D0210 |
Intraoral - complete series of radiographic images |
1,058 |
1,041 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,100 |
3,043 |
$38K |
| D7240 |
Removal of impacted tooth - completely bony |
133 |
52 |
$34K |
| D0274 |
Bitewings - four radiographic images |
2,419 |
2,341 |
$34K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
782 |
431 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,325 |
1,285 |
$30K |
| D3320 |
|
88 |
80 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,215 |
3,630 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
582 |
265 |
$26K |
| D1120 |
Prophylaxis - child |
879 |
841 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
4,212 |
4,070 |
$20K |
| D1206 |
Topical application of fluoride varnish |
899 |
861 |
$14K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
287 |
153 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
240 |
170 |
$13K |
| D4341 |
|
334 |
90 |
$12K |
| D4346 |
|
269 |
265 |
$9K |
| D8670 |
Periodic orthodontic treatment visit |
291 |
199 |
$7K |
| D9920 |
|
372 |
341 |
$6K |
| D4910 |
|
76 |
73 |
$4K |
| D2332 |
|
41 |
27 |
$2K |
| D2335 |
|
22 |
12 |
$1K |
| D2950 |
|
47 |
25 |
$1K |
| D0601 |
|
70 |
62 |
$570.00 |
| D9310 |
|
37 |
37 |
$570.00 |
| D0170 |
|
14 |
14 |
$325.00 |
| D0602 |
|
16 |
16 |
$140.00 |