| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
891 |
748 |
$535K |
| D1110 |
Prophylaxis - adult |
2,798 |
2,797 |
$149K |
| D0120 |
Periodic oral evaluation - established patient |
4,044 |
4,043 |
$109K |
| D0210 |
Intraoral - complete series of radiographic images |
1,569 |
1,569 |
$84K |
| D2954 |
|
433 |
389 |
$65K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
436 |
338 |
$27K |
| D0274 |
Bitewings - four radiographic images |
739 |
739 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
152 |
144 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
635 |
631 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
445 |
445 |
$6K |
| D3320 |
|
14 |
13 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
130 |
130 |
$2K |
| D1120 |
Prophylaxis - child |
14 |
14 |
$599.85 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$456.00 |
| D1999 |
|
17 |
16 |
$0.00 |