| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
284 |
146 |
$134K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
977 |
221 |
$53K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
392 |
392 |
$26K |
| D2954 |
|
191 |
110 |
$20K |
| D1110 |
Prophylaxis - adult |
229 |
229 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
306 |
306 |
$14K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
29 |
25 |
$13K |
| D2330 |
|
155 |
43 |
$12K |
| D3320 |
|
23 |
17 |
$8K |
| D4341 |
|
103 |
30 |
$7K |
| D0350 |
|
195 |
191 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
82 |
50 |
$5K |
| D9430 |
|
134 |
127 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
257 |
257 |
$3K |
| D0330 |
Panoramic radiographic image |
44 |
44 |
$1K |
| D1120 |
Prophylaxis - child |
24 |
24 |
$1K |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$172.00 |