| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,405 |
1,081 |
$99K |
| D1110 |
Prophylaxis - adult |
1,699 |
1,680 |
$53K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
99 |
65 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,781 |
1,768 |
$29K |
| D2330 |
|
441 |
204 |
$16K |
| D0272 |
Bitewings - two radiographic images |
1,228 |
1,222 |
$8K |
| D1120 |
Prophylaxis - child |
235 |
235 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
185 |
182 |
$5K |
| D1206 |
Topical application of fluoride varnish |
227 |
227 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
271 |
271 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
219 |
207 |
$805.00 |