| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
434 |
340 |
$232K |
| D1110 |
Prophylaxis - adult |
1,904 |
1,904 |
$84K |
| D0140 |
Limited oral evaluation - problem focused |
1,596 |
1,529 |
$69K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
851 |
310 |
$68K |
| D0210 |
Intraoral - complete series of radiographic images |
1,382 |
1,381 |
$68K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
119 |
109 |
$54K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
711 |
427 |
$51K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,848 |
1,848 |
$43K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
491 |
170 |
$39K |
| D2954 |
|
287 |
228 |
$37K |
| D0220 |
Intraoral - periapical first radiographic image |
2,746 |
2,558 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
353 |
196 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
645 |
645 |
$16K |
| D3320 |
|
28 |
26 |
$10K |
| D0274 |
Bitewings - four radiographic images |
605 |
605 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
365 |
365 |
$8K |
| D2332 |
|
100 |
29 |
$8K |
| D1120 |
Prophylaxis - child |
162 |
162 |
$7K |
| D2335 |
|
53 |
14 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,061 |
1,047 |
$4K |
| D0270 |
|
382 |
356 |
$3K |
| D2331 |
|
43 |
25 |
$3K |
| D4910 |
|
28 |
28 |
$3K |
| D2330 |
|
33 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
40 |
40 |
$2K |