| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
31 |
12 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
425 |
425 |
$11K |
| D1120 |
Prophylaxis - child |
193 |
193 |
$9K |
| D1206 |
Topical application of fluoride varnish |
217 |
217 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
48 |
28 |
$4K |
| D1110 |
Prophylaxis - adult |
73 |
73 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
611 |
592 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
48 |
15 |
$3K |
| D0274 |
Bitewings - four radiographic images |
173 |
173 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
42 |
39 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
63 |
63 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
449 |
446 |
$2K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$120.00 |