| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,839 |
942 |
$98K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
132 |
105 |
$63K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
877 |
876 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
917 |
911 |
$45K |
| D1120 |
Prophylaxis - child |
1,042 |
1,041 |
$37K |
| D0274 |
Bitewings - four radiographic images |
1,522 |
1,516 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
474 |
325 |
$31K |
| D1110 |
Prophylaxis - adult |
365 |
365 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,960 |
1,952 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,841 |
2,729 |
$23K |
| D9430 |
|
644 |
636 |
$20K |
| D0350 |
|
850 |
403 |
$7K |
| D2954 |
|
48 |
40 |
$5K |
| D0272 |
Bitewings - two radiographic images |
91 |
91 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$144.00 |