| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
329 |
188 |
$170K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
243 |
203 |
$163K |
| D1110 |
Prophylaxis - adult |
2,964 |
2,904 |
$126K |
| D2791 |
|
226 |
186 |
$124K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,643 |
707 |
$121K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
981 |
372 |
$117K |
| D3320 |
|
168 |
115 |
$82K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,092 |
324 |
$74K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,234 |
515 |
$74K |
| D0120 |
Periodic oral evaluation - established patient |
2,886 |
2,826 |
$68K |
| D0210 |
Intraoral - complete series of radiographic images |
1,014 |
988 |
$56K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,918 |
1,878 |
$54K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,126 |
2,087 |
$44K |
| D1120 |
Prophylaxis - child |
1,171 |
1,152 |
$39K |
| D0274 |
Bitewings - four radiographic images |
1,266 |
1,245 |
$33K |
| D0330 |
Panoramic radiographic image |
601 |
590 |
$25K |
| D1206 |
Topical application of fluoride varnish |
1,122 |
1,102 |
$24K |
| D4342 |
|
699 |
185 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
898 |
879 |
$19K |
| D7250 |
|
152 |
42 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
823 |
802 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
151 |
139 |
$4K |
| D1351 |
Sealant - per tooth |
121 |
27 |
$4K |
| D0272 |
Bitewings - two radiographic images |
122 |
120 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
99 |
97 |
$807.70 |