| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
40 |
28 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
248 |
248 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
89 |
44 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,214 |
229 |
$5K |
| D0274 |
Bitewings - four radiographic images |
146 |
146 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
40 |
24 |
$2K |
| D1120 |
Prophylaxis - child |
37 |
37 |
$2K |
| D0350 |
|
140 |
64 |
$1K |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
60 |
60 |
$901.00 |
| D0220 |
Intraoral - periapical first radiographic image |
46 |
43 |
$468.40 |
| D9430 |
|
13 |
13 |
$396.00 |