| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
87 |
74 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
578 |
316 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
479 |
479 |
$32K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
325 |
205 |
$26K |
| D1110 |
Prophylaxis - adult |
255 |
255 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
391 |
391 |
$19K |
| D0350 |
|
1,729 |
435 |
$16K |
| D1206 |
Topical application of fluoride varnish |
507 |
507 |
$8K |
| D1120 |
Prophylaxis - child |
160 |
160 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
83 |
53 |
$4K |
| D9430 |
|
116 |
107 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
33 |
33 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
417 |
92 |
$2K |
| D3221 |
|
16 |
16 |
$1K |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$259.20 |