| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
20 |
14 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
104 |
61 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
223 |
204 |
$3K |
| D1110 |
Prophylaxis - adult |
171 |
171 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
76 |
76 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
305 |
293 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
36 |
36 |
$1K |
| D2950 |
|
16 |
12 |
$777.60 |
| D0274 |
Bitewings - four radiographic images |
79 |
79 |
$711.00 |
| D0120 |
Periodic oral evaluation - established patient |
41 |
41 |
$615.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
164 |
164 |
$490.50 |