| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
181 |
127 |
$72K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,143 |
580 |
$43K |
| D1120 |
Prophylaxis - child |
1,617 |
1,613 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,575 |
1,575 |
$30K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
289 |
161 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
785 |
785 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
956 |
954 |
$17K |
| D1206 |
Topical application of fluoride varnish |
902 |
897 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
429 |
263 |
$15K |
| D1110 |
Prophylaxis - adult |
775 |
775 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
790 |
753 |
$14K |
| D1351 |
Sealant - per tooth |
867 |
151 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
828 |
828 |
$9K |
| D0603 |
|
910 |
900 |
$8K |
| D0274 |
Bitewings - four radiographic images |
614 |
614 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,516 |
1,502 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
924 |
924 |
$4K |
| D2954 |
|
32 |
29 |
$2K |
| D4341 |
|
55 |
24 |
$2K |
| D0272 |
Bitewings - two radiographic images |
284 |
283 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
33 |
27 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
113 |
97 |
$1K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$449.00 |
| D0601 |
|
16 |
16 |
$150.00 |
| D0602 |
|
15 |
15 |
$90.00 |