| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
57 |
29 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
361 |
356 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
376 |
73 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
228 |
56 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
197 |
195 |
$9K |
| D1110 |
Prophylaxis - adult |
66 |
65 |
$5K |
| D1206 |
Topical application of fluoride varnish |
261 |
259 |
$4K |
| D4341 |
|
50 |
13 |
$4K |
| D0350 |
|
329 |
86 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
118 |
35 |
$510.30 |
| D9430 |
|
15 |
13 |
$448.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$144.00 |