| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
22 |
13 |
$10K |
| D1120 |
Prophylaxis - child |
261 |
261 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
191 |
188 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,660 |
533 |
$8K |
| D0274 |
Bitewings - four radiographic images |
289 |
288 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
62 |
24 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
394 |
394 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
14 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$792.00 |