| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
43 |
34 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
249 |
249 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
127 |
59 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
80 |
47 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
82 |
45 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
982 |
191 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
75 |
75 |
$4K |
| D1120 |
Prophylaxis - child |
68 |
68 |
$4K |
| D4341 |
|
48 |
12 |
$3K |
| D1110 |
Prophylaxis - adult |
25 |
25 |
$2K |
| D0272 |
Bitewings - two radiographic images |
163 |
163 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
43 |
42 |
$605.50 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$185.50 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$144.00 |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$135.00 |