| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,109 |
398 |
$73K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
88 |
50 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
391 |
389 |
$26K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
298 |
147 |
$23K |
| D0210 |
Intraoral - complete series of radiographic images |
288 |
286 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
82 |
82 |
$6K |
| D1120 |
Prophylaxis - child |
63 |
63 |
$3K |
| D0274 |
Bitewings - four radiographic images |
139 |
139 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
502 |
217 |
$2K |
| D9430 |
|
38 |
37 |
$1K |
| D4910 |
|
15 |
15 |
$1K |
| D1206 |
Topical application of fluoride varnish |
30 |
30 |
$472.50 |