| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
307 |
166 |
$146K |
| D2954 |
|
282 |
159 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
439 |
437 |
$29K |
| D1110 |
Prophylaxis - adult |
201 |
201 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
239 |
107 |
$15K |
| D0330 |
Panoramic radiographic image |
324 |
324 |
$9K |
| D9430 |
|
236 |
213 |
$8K |
| D3320 |
|
19 |
14 |
$7K |
| D1120 |
Prophylaxis - child |
96 |
96 |
$5K |
| D4910 |
|
54 |
54 |
$4K |
| D4341 |
|
52 |
13 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
56 |
27 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
138 |
138 |
$2K |
| D1206 |
Topical application of fluoride varnish |
108 |
108 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
21 |
21 |
$960.00 |
| D0274 |
Bitewings - four radiographic images |
181 |
181 |
$648.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
86 |
24 |
$178.20 |