| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
163 |
65 |
$77K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
357 |
351 |
$23K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
231 |
86 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
271 |
97 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
210 |
66 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
217 |
211 |
$10K |
| D0350 |
|
723 |
301 |
$6K |
| D9430 |
|
144 |
138 |
$5K |
| D1110 |
Prophylaxis - adult |
50 |
48 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
223 |
87 |
$870.75 |
| D0220 |
Intraoral - periapical first radiographic image |
64 |
61 |
$756.00 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$237.60 |