| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
413 |
98 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
241 |
93 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
235 |
234 |
$16K |
| D4910 |
|
142 |
142 |
$11K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
20 |
13 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
140 |
139 |
$6K |
| D9430 |
|
104 |
93 |
$3K |
| D2954 |
|
23 |
15 |
$2K |
| D2330 |
|
26 |
13 |
$2K |
| D0350 |
|
339 |
53 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
200 |
42 |
$810.00 |
| D1206 |
Topical application of fluoride varnish |
42 |
42 |
$442.00 |