| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
157 |
72 |
$74K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
424 |
113 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
191 |
189 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
188 |
48 |
$10K |
| D4341 |
|
119 |
31 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
157 |
155 |
$7K |
| D0350 |
|
673 |
185 |
$6K |
| D1320 |
|
148 |
148 |
$2K |
| D2954 |
|
21 |
13 |
$2K |
| D2394 |
|
25 |
13 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
91 |
79 |
$1K |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$208.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
20 |
14 |
$81.00 |
| D0470 |
|
64 |
62 |
$0.00 |
| D1310 |
|
61 |
59 |
$0.00 |