| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
343 |
242 |
$132K |
| D7140 |
Extraction, erupted tooth or exposed root |
998 |
508 |
$124K |
| D1110 |
Prophylaxis - adult |
1,544 |
1,529 |
$97K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
532 |
393 |
$89K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
659 |
459 |
$88K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,054 |
3,016 |
$71K |
| D0274 |
Bitewings - four radiographic images |
2,863 |
2,819 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
2,029 |
1,994 |
$60K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
509 |
316 |
$54K |
| D1120 |
Prophylaxis - child |
1,201 |
1,176 |
$51K |
| D0330 |
Panoramic radiographic image |
1,085 |
1,074 |
$49K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
64 |
62 |
$48K |
| D0220 |
Intraoral - periapical first radiographic image |
4,029 |
3,918 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
743 |
735 |
$40K |
| D0140 |
Limited oral evaluation - problem focused |
753 |
737 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,778 |
2,735 |
$26K |
| D2335 |
|
124 |
78 |
$22K |
| D3320 |
|
29 |
26 |
$19K |
| D2332 |
|
96 |
51 |
$14K |
| D1330 |
|
1,333 |
1,303 |
$8K |
| D1351 |
Sealant - per tooth |
197 |
27 |
$7K |
| D2954 |
|
60 |
40 |
$4K |
| D2950 |
|
31 |
26 |
$3K |
| D4355 |
|
19 |
19 |
$2K |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$420.00 |