| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,170 |
566 |
$78K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
107 |
75 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
690 |
690 |
$45K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
545 |
270 |
$29K |
| D0210 |
Intraoral - complete series of radiographic images |
410 |
409 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
241 |
154 |
$19K |
| D9430 |
|
334 |
299 |
$11K |
| D1110 |
Prophylaxis - adult |
82 |
82 |
$7K |
| D0274 |
Bitewings - four radiographic images |
142 |
142 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
368 |
204 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
14 |
14 |
$1K |
| D0350 |
|
104 |
101 |
$945.60 |
| D1120 |
Prophylaxis - child |
28 |
28 |
$772.50 |
| D0220 |
Intraoral - periapical first radiographic image |
38 |
38 |
$288.00 |