| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
294 |
260 |
$159K |
| D1110 |
Prophylaxis - adult |
2,309 |
2,309 |
$103K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,445 |
855 |
$101K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,038 |
522 |
$88K |
| D0120 |
Periodic oral evaluation - established patient |
3,295 |
3,295 |
$82K |
| D1120 |
Prophylaxis - child |
1,501 |
1,501 |
$67K |
| D0140 |
Limited oral evaluation - problem focused |
1,170 |
1,141 |
$52K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,508 |
1,508 |
$38K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
586 |
348 |
$32K |
| D0274 |
Bitewings - four radiographic images |
2,330 |
2,330 |
$28K |
| D0210 |
Intraoral - complete series of radiographic images |
594 |
594 |
$27K |
| D2954 |
|
237 |
207 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
4,370 |
4,162 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
553 |
553 |
$14K |
| D1351 |
Sealant - per tooth |
671 |
104 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,160 |
3,142 |
$11K |
| D9920 |
|
289 |
282 |
$7K |
| D1206 |
Topical application of fluoride varnish |
211 |
211 |
$7K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
13 |
12 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
263 |
239 |
$6K |
| D0272 |
Bitewings - two radiographic images |
482 |
481 |
$5K |
| D4355 |
|
40 |
40 |
$5K |
| D2394 |
|
33 |
30 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
57 |
34 |
$3K |
| D2332 |
|
38 |
24 |
$3K |
| D2331 |
|
21 |
14 |
$1K |
| D2330 |
|
17 |
14 |
$850.00 |
| D0601 |
|
69 |
69 |
$690.00 |
| D0270 |
|
108 |
107 |
$540.00 |
| D0603 |
|
51 |
51 |
$510.00 |