| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
288 |
223 |
$133K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
858 |
850 |
$54K |
| D1110 |
Prophylaxis - adult |
695 |
688 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
729 |
392 |
$45K |
| D4910 |
|
589 |
589 |
$43K |
| D4341 |
|
554 |
151 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
369 |
364 |
$28K |
| D2954 |
|
211 |
162 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
473 |
470 |
$20K |
| D9430 |
|
503 |
467 |
$15K |
| D1120 |
Prophylaxis - child |
282 |
282 |
$14K |
| D1320 |
|
956 |
949 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
141 |
95 |
$11K |
| D1206 |
Topical application of fluoride varnish |
556 |
556 |
$9K |
| D0274 |
Bitewings - four radiographic images |
431 |
429 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
564 |
554 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,687 |
565 |
$7K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
12 |
12 |
$5K |
| D1351 |
Sealant - per tooth |
62 |
13 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
62 |
62 |
$648.00 |