| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,424 |
543 |
$82K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
181 |
112 |
$53K |
| D1110 |
Prophylaxis - adult |
1,073 |
1,073 |
$38K |
| D2954 |
|
292 |
172 |
$25K |
| D0274 |
Bitewings - four radiographic images |
940 |
940 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
787 |
787 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
257 |
139 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,383 |
1,376 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
625 |
623 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
174 |
70 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,150 |
1,148 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
296 |
296 |
$3K |
| D3320 |
|
18 |
13 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
189 |
187 |
$3K |
| D1120 |
Prophylaxis - child |
81 |
81 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
252 |
248 |
$2K |
| D0330 |
Panoramic radiographic image |
90 |
90 |
$2K |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$258.50 |