| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
498 |
498 |
$33K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
58 |
50 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
283 |
175 |
$19K |
| D1120 |
Prophylaxis - child |
246 |
246 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
208 |
117 |
$11K |
| D1110 |
Prophylaxis - adult |
125 |
124 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
197 |
197 |
$9K |
| D9430 |
|
235 |
217 |
$8K |
| D0350 |
|
384 |
321 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
581 |
420 |
$5K |
| D1351 |
Sealant - per tooth |
127 |
38 |
$5K |
| D0274 |
Bitewings - four radiographic images |
206 |
206 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
247 |
247 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
218 |
206 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
32 |
27 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
24 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$300.00 |