| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
48 |
41 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
160 |
144 |
$13K |
| D1110 |
Prophylaxis - adult |
296 |
296 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
463 |
462 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
544 |
529 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
73 |
68 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
556 |
551 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
359 |
351 |
$4K |
| D2954 |
|
31 |
27 |
$3K |
| D4341 |
|
20 |
13 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
64 |
64 |
$709.20 |
| D0272 |
Bitewings - two radiographic images |
55 |
55 |
$688.05 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$154.02 |