| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
47 |
27 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
186 |
186 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
166 |
166 |
$8K |
| D1110 |
Prophylaxis - adult |
63 |
63 |
$5K |
| D0350 |
|
439 |
128 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
51 |
25 |
$3K |
| D1206 |
Topical application of fluoride varnish |
126 |
126 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
24 |
13 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$1K |