| Code | Description | Claims | Beneficiaries | Total Paid |
| D2751 |
Crown - porcelain fused to predominantly base metal |
609 |
453 |
$315K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
3,643 |
1,430 |
$238K |
| D1110 |
Prophylaxis - adult |
4,677 |
4,609 |
$182K |
| D1120 |
Prophylaxis - child |
4,220 |
4,184 |
$182K |
| D0120 |
Periodic oral evaluation - established patient |
7,664 |
7,577 |
$177K |
| D0140 |
Limited oral evaluation - problem focused |
4,452 |
4,317 |
$159K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,855 |
3,819 |
$84K |
| D1351 |
Sealant - per tooth |
3,576 |
509 |
$82K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,701 |
1,110 |
$79K |
| D2740 |
Crown - porcelain/ceramic |
164 |
125 |
$71K |
| D0210 |
Intraoral - complete series of radiographic images |
1,287 |
1,285 |
$63K |
| D2954 |
|
628 |
499 |
$55K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,072 |
2,054 |
$43K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
993 |
614 |
$40K |
| D0330 |
Panoramic radiographic image |
2,277 |
2,240 |
$37K |
| D0274 |
Bitewings - four radiographic images |
3,496 |
3,441 |
$31K |
| D1206 |
Topical application of fluoride varnish |
909 |
902 |
$30K |
| D2752 |
|
58 |
40 |
$26K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
263 |
172 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
3,491 |
3,388 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
529 |
470 |
$12K |
| D0272 |
Bitewings - two radiographic images |
1,227 |
1,215 |
$11K |
| D9920 |
|
455 |
395 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
282 |
158 |
$10K |
| D0603 |
|
395 |
395 |
$4K |
| D0601 |
|
341 |
340 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
17 |
15 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
707 |
518 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
17 |
15 |
$1K |
| D0602 |
|
27 |
27 |
$230.00 |
| D0270 |
|
27 |
27 |
$108.50 |
| D1999 |
|
39 |
36 |
$0.00 |