| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
417 |
331 |
$205K |
| D0120 |
Periodic oral evaluation - established patient |
9,648 |
9,640 |
$194K |
| D1110 |
Prophylaxis - adult |
5,326 |
5,323 |
$194K |
| D1120 |
Prophylaxis - child |
4,311 |
4,309 |
$143K |
| D1351 |
Sealant - per tooth |
2,099 |
1,189 |
$126K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,795 |
1,492 |
$123K |
| D0220 |
Intraoral - periapical first radiographic image |
9,878 |
9,488 |
$85K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,788 |
4,788 |
$54K |
| D0272 |
Bitewings - two radiographic images |
4,170 |
4,169 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,182 |
2,182 |
$48K |
| D0330 |
Panoramic radiographic image |
2,080 |
2,080 |
$45K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,572 |
6,505 |
$41K |
| D8670 |
Periodic orthodontic treatment visit |
162 |
162 |
$37K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
320 |
272 |
$30K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
369 |
327 |
$27K |
| D2954 |
|
201 |
160 |
$23K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
281 |
241 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
1,489 |
1,407 |
$19K |
| D0274 |
Bitewings - four radiographic images |
973 |
973 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
1,895 |
1,764 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
312 |
232 |
$13K |
| D1206 |
Topical application of fluoride varnish |
609 |
608 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
271 |
250 |
$10K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
30 |
26 |
$8K |
| D3320 |
|
33 |
29 |
$7K |
| D8660 |
|
123 |
123 |
$3K |
| D0340 |
|
79 |
79 |
$3K |
| D3240 |
|
39 |
31 |
$3K |
| D2332 |
|
17 |
17 |
$2K |
| D0470 |
|
69 |
69 |
$2K |
| D0350 |
|
95 |
95 |
$938.78 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
14 |
12 |
$895.69 |
| D9310 |
|
18 |
18 |
$579.51 |
| D0270 |
|
46 |
46 |
$415.85 |
| D9110 |
|
17 |
17 |
$300.48 |
| D7111 |
|
12 |
12 |
$220.10 |
| D1999 |
|
39 |
33 |
$0.00 |