| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
51 |
28 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
228 |
215 |
$12K |
| D1110 |
Prophylaxis - adult |
112 |
111 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
136 |
134 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
28 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
147 |
147 |
$2K |
| D1320 |
|
102 |
101 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
12 |
$1K |
| D0350 |
|
39 |
32 |
$768.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
85 |
30 |
$341.55 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
12 |
$156.00 |
| D0120 |
Periodic oral evaluation - established patient |
14 |
13 |
$105.00 |
| D0272 |
Bitewings - two radiographic images |
17 |
14 |
$70.00 |