| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
80 |
56 |
$43K |
| D1110 |
Prophylaxis - adult |
826 |
803 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
287 |
147 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
740 |
718 |
$17K |
| D0274 |
Bitewings - four radiographic images |
221 |
211 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
249 |
241 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
128 |
121 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
77 |
42 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
306 |
282 |
$4K |
| D1120 |
Prophylaxis - child |
79 |
76 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
24 |
15 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
32 |
30 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
43 |
40 |
$516.00 |