| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
412 |
411 |
$26K |
| D1120 |
Prophylaxis - child |
226 |
225 |
$11K |
| D1351 |
Sealant - per tooth |
278 |
78 |
$10K |
| D1999 |
|
512 |
456 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
215 |
215 |
$10K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
158 |
87 |
$10K |
| D2160 |
|
111 |
55 |
$9K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
15 |
12 |
$7K |
| D4910 |
|
97 |
97 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,600 |
340 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
303 |
302 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
77 |
60 |
$3K |
| D2335 |
|
20 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
121 |
121 |
$2K |
| D9430 |
|
65 |
61 |
$2K |
| D1110 |
Prophylaxis - adult |
24 |
24 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
178 |
168 |
$2K |
| D0350 |
|
213 |
89 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
18 |
$1K |
| D2940 |
|
19 |
14 |
$1K |
| D2331 |
|
17 |
13 |
$1K |
| D9110 |
|
16 |
14 |
$1K |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$156.00 |