| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
729 |
361 |
$56K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
63 |
42 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
1,335 |
1,333 |
$37K |
| D1120 |
Prophylaxis - child |
647 |
647 |
$32K |
| D1110 |
Prophylaxis - adult |
604 |
603 |
$30K |
| D1206 |
Topical application of fluoride varnish |
801 |
801 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
414 |
225 |
$25K |
| D1351 |
Sealant - per tooth |
751 |
96 |
$17K |
| D4355 |
|
103 |
103 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
138 |
91 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
182 |
182 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
180 |
171 |
$9K |
| D0274 |
Bitewings - four radiographic images |
622 |
621 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
280 |
280 |
$8K |
| D0330 |
Panoramic radiographic image |
167 |
167 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,047 |
1,020 |
$6K |
| D2950 |
|
62 |
41 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
635 |
634 |
$2K |
| D9920 |
|
45 |
44 |
$1K |
| D0603 |
|
76 |
76 |
$836.00 |
| D1320 |
|
82 |
82 |
$793.00 |
| D0602 |
|
63 |
63 |
$693.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
13 |
$385.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$143.00 |