| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,737 |
1,737 |
$93K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
464 |
396 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,571 |
1,571 |
$42K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
37 |
37 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
635 |
633 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
241 |
241 |
$12K |
| D0274 |
Bitewings - four radiographic images |
396 |
396 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
94 |
79 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
160 |
158 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$198.00 |