| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
53 |
34 |
$31K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
253 |
98 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
671 |
653 |
$22K |
| D0274 |
Bitewings - four radiographic images |
671 |
651 |
$16K |
| D0330 |
Panoramic radiographic image |
728 |
710 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
179 |
66 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
904 |
862 |
$11K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
81 |
28 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
685 |
654 |
$6K |
| D1110 |
Prophylaxis - adult |
107 |
104 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
166 |
163 |
$4K |
| D1206 |
Topical application of fluoride varnish |
178 |
170 |
$4K |
| D4342 |
|
78 |
27 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
17 |
$2K |
| D0270 |
|
122 |
119 |
$1K |
| D2330 |
|
14 |
12 |
$1K |
| D4346 |
|
13 |
13 |
$579.12 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
16 |
14 |
$547.50 |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$313.30 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
12 |
$202.95 |
| D0350 |
|
1,589 |
861 |
$0.00 |
| D2950 |
|
18 |
14 |
$0.00 |
| D4921 |
|
142 |
37 |
$0.00 |
| D0431 |
|
60 |
57 |
$0.00 |
| D0801 |
|
662 |
640 |
$0.00 |