| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
127 |
61 |
$127K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
385 |
181 |
$108K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
298 |
138 |
$74K |
| D4341 |
|
242 |
76 |
$73K |
| D4342 |
|
304 |
81 |
$61K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
167 |
108 |
$53K |
| D2950 |
|
215 |
100 |
$43K |
| D0210 |
Intraoral - complete series of radiographic images |
187 |
187 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
189 |
189 |
$19K |
| D3320 |
|
15 |
12 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
187 |
187 |
$7K |
| D3221 |
|
21 |
12 |
$7K |
| D4910 |
|
44 |
43 |
$7K |
| D2331 |
|
21 |
12 |
$5K |
| D1310 |
|
45 |
45 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
43 |
43 |
$860.00 |