| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
933 |
762 |
$400K |
| D2750 |
|
600 |
513 |
$259K |
| D0120 |
Periodic oral evaluation - established patient |
7,582 |
7,573 |
$165K |
| D1110 |
Prophylaxis - adult |
7,248 |
7,245 |
$157K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
338 |
324 |
$134K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,683 |
1,679 |
$116K |
| D2954 |
|
1,335 |
1,151 |
$110K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,793 |
1,085 |
$108K |
| D0274 |
Bitewings - four radiographic images |
5,800 |
5,800 |
$80K |
| D1120 |
Prophylaxis - child |
2,720 |
2,720 |
$73K |
| D0140 |
Limited oral evaluation - problem focused |
3,347 |
3,231 |
$73K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,678 |
1,096 |
$63K |
| D3320 |
|
200 |
191 |
$59K |
| D1206 |
Topical application of fluoride varnish |
3,337 |
3,337 |
$55K |
| D1351 |
Sealant - per tooth |
3,168 |
466 |
$52K |
| D0220 |
Intraoral - periapical first radiographic image |
11,180 |
10,764 |
$49K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,365 |
2,365 |
$49K |
| D0330 |
Panoramic radiographic image |
1,742 |
1,742 |
$47K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,208 |
9,680 |
$46K |
| D9920 |
|
1,869 |
1,736 |
$31K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
581 |
415 |
$29K |
| D4341 |
|
380 |
141 |
$17K |
| D0272 |
Bitewings - two radiographic images |
1,876 |
1,873 |
$14K |
| D1320 |
|
1,429 |
1,429 |
$14K |
| D8670 |
Periodic orthodontic treatment visit |
258 |
244 |
$14K |
| D0601 |
|
1,058 |
1,058 |
$10K |
| D9910 |
|
1,338 |
1,338 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
147 |
137 |
$6K |
| D0603 |
|
479 |
479 |
$5K |
| D4910 |
|
55 |
55 |
$3K |
| D3310 |
|
13 |
12 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
53 |
53 |
$2K |
| D1353 |
|
153 |
25 |
$2K |
| D2332 |
|
24 |
12 |
$1K |
| D9944 |
|
12 |
12 |
$1K |
| D2331 |
|
22 |
14 |
$968.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
12 |
$906.25 |
| D0270 |
|
199 |
199 |
$892.50 |
| D0602 |
|
17 |
17 |
$170.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
35 |
35 |
$11.00 |
| D1999 |
|
19 |
19 |
$0.00 |