| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,726 |
1,726 |
$94K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
97 |
78 |
$67K |
| D0274 |
Bitewings - four radiographic images |
1,359 |
1,357 |
$45K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
454 |
270 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
1,463 |
1,462 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
2,206 |
2,169 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
894 |
894 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
257 |
174 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,657 |
1,652 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
363 |
363 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
308 |
300 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
163 |
163 |
$10K |
| D2954 |
|
18 |
12 |
$2K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$660.00 |