| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
225 |
155 |
$107K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,155 |
520 |
$76K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,115 |
1,109 |
$74K |
| D1120 |
Prophylaxis - child |
805 |
800 |
$41K |
| D0210 |
Intraoral - complete series of radiographic images |
828 |
828 |
$40K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
337 |
189 |
$27K |
| D0350 |
|
2,565 |
842 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
429 |
216 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
307 |
307 |
$23K |
| D4341 |
|
327 |
88 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,257 |
1,083 |
$22K |
| D2954 |
|
213 |
149 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
887 |
882 |
$16K |
| D9430 |
|
457 |
435 |
$15K |
| D0340 |
|
262 |
262 |
$13K |
| D1110 |
Prophylaxis - adult |
144 |
144 |
$13K |
| D4910 |
|
146 |
146 |
$11K |
| D1320 |
|
619 |
619 |
$11K |
| D0330 |
Panoramic radiographic image |
328 |
328 |
$10K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
18 |
17 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
171 |
171 |
$7K |
| D1310 |
|
149 |
149 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
455 |
443 |
$5K |
| D1206 |
Topical application of fluoride varnish |
262 |
262 |
$5K |
| D0274 |
Bitewings - four radiographic images |
120 |
120 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
27 |
12 |
$2K |
| D0603 |
|
113 |
113 |
$2K |
| D0272 |
Bitewings - two radiographic images |
70 |
69 |
$816.00 |