| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
243 |
188 |
$116K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,533 |
1,529 |
$100K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,286 |
587 |
$86K |
| D0210 |
Intraoral - complete series of radiographic images |
1,139 |
1,139 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
624 |
623 |
$46K |
| D1120 |
Prophylaxis - child |
967 |
964 |
$44K |
| D4910 |
|
456 |
453 |
$35K |
| D0350 |
|
3,142 |
1,085 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,297 |
1,274 |
$27K |
| D4341 |
|
363 |
98 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,565 |
1,551 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
406 |
204 |
$22K |
| D1110 |
Prophylaxis - adult |
237 |
231 |
$21K |
| D2954 |
|
186 |
145 |
$20K |
| D1320 |
|
978 |
977 |
$16K |
| D9430 |
|
432 |
412 |
$14K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
26 |
26 |
$12K |
| D0330 |
Panoramic radiographic image |
399 |
399 |
$12K |
| D0340 |
|
217 |
215 |
$11K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
78 |
47 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
73 |
43 |
$6K |
| D3320 |
|
15 |
13 |
$5K |
| D0274 |
Bitewings - four radiographic images |
192 |
192 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
76 |
76 |
$3K |
| D1310 |
|
57 |
57 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
150 |
148 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
29 |
14 |
$2K |
| D1206 |
Topical application of fluoride varnish |
43 |
43 |
$752.00 |
| D0603 |
|
44 |
44 |
$630.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$156.00 |
| D9993 |
|
12 |
12 |
$0.00 |